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Goldstein DP, Blasco M, de Almeida J, Su J, Xu W, Cohen M, Sklar M, Alibhai S. Cognitive Impairment and Delirium in Older Patients Undergoing Major Head and Neck Surgery. Otolaryngol Head Neck Surg 2021; 167:97-99. [PMID: 34546809 PMCID: PMC9251740 DOI: 10.1177/01945998211045293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The study objective was to measure the prevalence and predictors of cognitive
impairment (CI) and delirium. Adults undergoing major head and neck cancer
surgery completed the Clock Draw Test to screen for CI, defined as a score of 0
or 1. Postoperative delirium was recorded. Predictors of delirium and length of
stay were assessed by univariate logistic regression and the latter with
multivariate linear regression. Overall 274 patients were included, of which 47%
had a Clock Draw Test score of 0 or 1. Post-operative delirium occurred in 17
(6%). CI was a predictor of postoperative delirium (odds ratio, 3.9; 95% CI,
1.2-12; P = .02). Postoperative delirium was a predictor of
increased length of stay (adjusted odds ratio, 1.30; 95% CI, 1.07-1.57;
P = .0073) on multivariate regression while baseline Clock
Draw Test result was not a predictor on univariate regression
(P = .98). Screening for CI can help predict delirium and
facilitate targeted interventions in the postoperative period.
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Affiliation(s)
- David P Goldstein
- Departments of Otolaryngology-Head and Neck Surgery and Surgical Oncology, Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Michael Blasco
- Departments of Otolaryngology-Head and Neck Surgery and Surgical Oncology, Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - John de Almeida
- Departments of Otolaryngology-Head and Neck Surgery and Surgical Oncology, Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Jie Su
- Department of Biostatistics, Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Wei Xu
- Department of Biostatistics, Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Marc Cohen
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Shabbir Alibhai
- Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
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Bouati N, Drevet S, Zerhouni N, Bioteau C, Mitha N, Gavazzi G. Cognitive Screening Tool for Geriatrics: A Retrospective Observational Study on the Correlation of the Scores in 30-Point Clock Face Test and MMSE. Indian J Psychol Med 2021; 43:306-311. [PMID: 34385723 PMCID: PMC8327860 DOI: 10.1177/0253717620961335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Over the past 30 years, the clock drawing test (CDT) has generated considerable interest due to its usefulness in the early detection of cognitive impairments, particularly those seen in neurodegenerative dementias (including Alzheimer's disease), vascular dementia, and mixed dementia. The present study aimed to determine whether the results of the "30-Point Clock Face Test" (CFT-30), a standardized version of the CDT that uses a 30-point scale, correlate with those of the Mini-Mental State Examination (MMSE). METHODS This is a retrospective, observational study. All patients hospitalized in a Hospital-University Clinic Geriatrics Unit (Grenoble Alpes University Hospital, Grenoble, France), from January 1, 2017, to December 31, 2018, were included. Patient data and scores were retrieved from hospital archives, and the results of the two tests of interest, MMSE and the CFT-30, were analyzed. RESULTS We included 214 patients aged ≥75 years. The mean ± SD age was 86.4 ± 5.6 years, and 68.7% were female. A strongly positive, significant correlation was seen between the CFT-30 and MMSE (r = 0.73, P < 0.001) scores. The total scores obtained by these two tests were identical (t = 1.22, P = 0.22). CONCLUSION CFT-30 is a good complement to the tools usually used in the investigation of cognitive impairments in older people. In addition to its metrological qualities, the standardized and normalized CFT-30 is extremely simple and very fast to use.
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Affiliation(s)
- Noureddine Bouati
- Hospital-University Clinic Geriatrics Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Sabine Drevet
- Hospital-University Clinic Geriatrics Unit, Grenoble Alpes University Hospital, Grenoble, France.,OrthoGeriatric Unit, Grenoble Alpes University Hospital, Grenoble, France.,Clinic of Geriatric Medicine, Grenoble Alpes University, Grenoble, France
| | - Nabil Zerhouni
- Hospital-University Clinic Geriatrics Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Catherine Bioteau
- OrthoGeriatric Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Nathalie Mitha
- Hospital-University Clinic Geriatrics Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Gaëtan Gavazzi
- Hospital-University Clinic Geriatrics Unit, Grenoble Alpes University Hospital, Grenoble, France.,Research and Studies Group of the Inflammatory Process (GREPI) EA 7408, Grenoble Alpes University, Grenoble, France
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3
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Wang Z, Zhang Y, Dong L, Zheng Z, Zhong D, Long X, Cai Q, Jian W, Zhang S, Wu W, Yao D. Effects of Morning Blue-Green 500 nm Light Therapy on Cognition and Biomarkers in Middle-Aged and Older Adults with Subjective Cognitive Decline and Mild Cognitive Impairment: Study Protocol for a Randomized Controlled Trial. J Alzheimers Dis 2021; 83:1521-1536. [PMID: 33843675 DOI: 10.3233/jad-201560] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Given that there is no specific drug to treat Alzheimer's disease, non-pharmacologic interventions in people with subjective cognitive decline (SCD) and amnestic mild cognitive impairment (aMCI) are one of the most important treatment strategies. OBJECTIVE To clarify the efficacy of blue-green (500 nm) light therapy on sleep, mood, and physiological parameters in patients with SCD and aMCI is an interesting avenue to explore. METHODS This is a monocentric, randomized, and controlled trial that will last for 4 weeks. We will recruit 150 individuals aged 45 years or older from memory clinics and divide them into 5 groups: SCD treatment (n = 30), SCD control (n = 30), aMCI treatment (n = 30), aMCI control (n = 30), and a group of healthy adult subjects (n = 30) as a normal control (NC). RESULTS The primary outcome is the change in subjective and objective cognitive performance between baseline and postintervention visits (4 weeks after baseline). Secondary outcomes include changes in performance assessing from baseline, postintervention to follow-up (3 months after the intervention), as well as sleep, mood, and physiological parameters (including blood, urine, electrophysiology, and neuroimaging biomarkers). CONCLUSION This study aims to provide evidence of the impact of light therapy on subjective and objective cognitive performance in middle-aged and older adults with SCD or aMCI. In addition, we will identify possible neurophysiological mechanisms of action underlying light therapy. Overall, this trial will contribute to the establishment of light therapy in the prevention of Alzheimer's disease.
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Affiliation(s)
- Ziqi Wang
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China.,The Memory Clinic of department of Neurology, Chengdu Western Hospital, Chengdu, China
| | - Yige Zhang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Li Dong
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China.,Research Unit of NeuroInformation, Chinese Academy of Medical Sciences, Chengdu, China.,Sichuan Institute for Brain Science and Brain-Inspired Intelligence, Chengdu, China
| | - Zihao Zheng
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Dayong Zhong
- Sichuan Provincial Revolutionary Disabled Soldiers Hospital, Chengdu, China
| | - Xunqin Long
- The Memory Clinic of department of Neurology, Chengdu Western Hospital, Chengdu, China
| | - Qingyan Cai
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Wei Jian
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Songge Zhang
- The Memory Clinic of department of Neurology, Chengdu Western Hospital, Chengdu, China
| | - Wenbin Wu
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dezhong Yao
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China.,Research Unit of NeuroInformation, Chinese Academy of Medical Sciences, Chengdu, China.,School of Electrical Engineering, Zhengzhou University, Zhengzhou, China.,Sichuan Institute for Brain Science and Brain-Inspired Intelligence, Chengdu, China
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4
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Hwang AB, Boes S, Nyffeler T, Schuepfer G. Validity of screening instruments for the detection of dementia and mild cognitive impairment in hospital inpatients: A systematic review of diagnostic accuracy studies. PLoS One 2019; 14:e0219569. [PMID: 31344048 PMCID: PMC6657852 DOI: 10.1371/journal.pone.0219569] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/26/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION As the population ages, Alzheimer's disease and other subtypes of dementia are becoming increasingly prevalent. However, in recent years, diagnosis has often been delayed or not made at all. Thus, improving the rate of diagnosis has become an integral part of national dementia strategies. Although screening for dementia remains controversial, the case is strong for screening for dementia and other forms of cognitive impairment in hospital inpatients. For this reason, the objective of this systematic review was to provide clinicians, who wish to implement screening, an up-to-date choice of cognitive tests with the most extensive evidence base for the use in elective hospital inpatients. METHODS For this systematic review, PubMed, PsycINFO and Cochrane Library were searched by using a multi-concept search strategy. The databases were accessed on April 10, 2019. All cross-sectional studies that utilized brief, multi-domain cognitive tests as index test and a reference standard diagnosis of dementia or mild cognitive impairment as comparator were included. Only studies conducted in the hospital setting, sampling from unselected, elective inpatients older than 64 were considered. RESULTS Six studies met the inclusion criteria, with a total of 2112 participants. Diagnostic accuracy data for the Six-Item Cognitive Impairment Test, Cognitive Performance Scale, Clock-Drawing Test, Mini-Mental Status Examination, and Time & Change test were extracted and descriptively analyzed. Clinical and methodological heterogeneity between the studies precluded performing a meta-analysis. DISCUSSION This review found only a small number of instruments and was not able to recommend a single best instrument for use in a hospital setting. Although it was not possible to estimate the pooled operating characteristics, the included description of instrument characteristics, the descriptive analysis of performance measures, and the critical evaluation of the reporting studies may contribute to clinician's choice of the screening instrument that fits best their purpose.
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Affiliation(s)
- Aljoscha Benjamin Hwang
- Clinic for Neurology and Neurorehabilitation, Cantonal Hospital Lucerne, Lucerne, Switzerland
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
| | - Stefan Boes
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
| | - Thomas Nyffeler
- Clinic for Neurology and Neurorehabilitation, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Guido Schuepfer
- Staff Medicine, Cantonal Hospital Lucerne, Lucerne, Switzerland
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5
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Rose M, Yang A, Welz M, Masik A, Staples M. Novel modification of the Reported Edmonton Frail Scale. Australas J Ageing 2018; 37:305-308. [PMID: 29635729 DOI: 10.1111/ajag.12533] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Michael Rose
- Cabrini Medical Centre, Melbourne, Victoria, Australia
| | - Allan Yang
- Monash Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Martina Welz
- Cabrini Medical Centre, Melbourne, Victoria, Australia
| | - Anna Masik
- Cabrini Medical Centre, Melbourne, Victoria, Australia
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Palsetia D, Rao GP, Tiwari SC, Lodha P, De Sousa A. The Clock Drawing Test versus Mini-mental Status Examination as a Screening Tool for Dementia: A Clinical Comparison. Indian J Psychol Med 2018; 40:1-10. [PMID: 29403122 PMCID: PMC5795671 DOI: 10.4103/ijpsym.ijpsym_244_17] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Delnaz Palsetia
- Department of Psychiatry, Asha Hospital, Hyderabad, Telangana, India
| | - G. Prasad Rao
- Department of Psychiatry, Asha Hospital, Hyderabad, Telangana, India
| | - Sarvada C. Tiwari
- Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Pragya Lodha
- Department of Research Assistant, Desousa Foundation, Mumbai, Maharashtra, India
| | - Avinash De Sousa
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
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7
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Daveckaite A, Grusauskiene E, Petrikonis K, Vaitkus A, Siaudvytyte L, Januleviciene I. Cognitive functions and normal tension glaucoma. Indian J Ophthalmol 2017; 65:974-978. [PMID: 29044063 PMCID: PMC5678334 DOI: 10.4103/ijo.ijo_756_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose: Only a few studies have analyzed the potential link between glaucoma and cognitive function impairment. They have found controversial results. This study aims to perform quick cognitive function assessment with clock drawing test (CDT) using two different scoring systems and compare between normal tension glaucoma (NTG) and cataract patients. Methods: Totally, 30 NTG and 30 patients with cataracts were included in a prospective, pilot study. The predrawn circle was given, and patients were asked to draw the clock showing a time of 11:10. The test was evaluated using two methods – Freund method using a 7-point scoring scale (optimal cutoff ≤4) and Rakusa using a 4-point scoring scale (optimal cutoff ≤3). The level of significance was set at P < 0.05. Results: CDT result was significantly better in cataract group than in NTG group: 3.5 (2) versus 2 (2) by Freund, (P = 0.003) and 6.5 (1) versus 4.5 (2.75) by Rakusa, respectively (P = 0.004). Sixty percent (n = 18) of NTG group and 10% (n = 3) of cataract group patients completed the CDT in the specific picture manner (the short hand on 11 and the long hand between 11 and 12), (P = 0.001). Conclusions: Lower CDT results were seen in NTG patients according to two different scoring systems. NTG patients showed a specific manner of drawing. Further prospective studies are needed to investigate the CDT reliability as fast screening test of cognitive function impairment in glaucoma patients.
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Affiliation(s)
- Akvile Daveckaite
- Department of Ophthalmology, Lithuanian University of Health Sciences, Kaunas 50009, Lithuania
| | - Evelina Grusauskiene
- Department of Neurology, Lithuanian University of Health Sciences, Kaunas 50009, Lithuania
| | - Kestutis Petrikonis
- Department of Neurology, Lithuanian University of Health Sciences, Kaunas 50009, Lithuania
| | - Antanas Vaitkus
- Department of Neurology, Lithuanian University of Health Sciences, Kaunas 50009, Lithuania
| | - Lina Siaudvytyte
- Department of Ophthalmology, Lithuanian University of Health Sciences, Kaunas 50009, Lithuania
| | - Ingrida Januleviciene
- Department of Ophthalmology, Lithuanian University of Health Sciences, Kaunas 50009, Lithuania
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8
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Spenciere B, Alves H, Charchat-Fichman H. Scoring systems for the Clock Drawing Test: A historical review. Dement Neuropsychol 2017; 11:6-14. [PMID: 29213488 PMCID: PMC5619209 DOI: 10.1590/1980-57642016dn11-010003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The Clock Drawing Test (CDT) is a simple neuropsychological screening instrument
that is well accepted by patients and has solid psychometric properties. Several
different CDT scoring methods have been developed, but no consensus has been
reached regarding which scoring method is the most accurate. This article
reviews the literature on these scoring systems and the changes they have
undergone over the years. Historically, different types of scoring systems
emerged. Initially, the focus was on screening for dementia, and the methods
were both quantitative and semi-quantitative. Later, the need for an early
diagnosis called for a scoring system that can detect subtle errors, especially
those related to executive function. Therefore, qualitative analyses began to be
used for both differential and early diagnoses of dementia. A widely used
qualitative method was proposed by Rouleau et al. (1992). Tracing the historical
path of these scoring methods is important for developing additional scoring
systems and furthering dementia prevention research.
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Affiliation(s)
- Bárbara Spenciere
- BsC, Department of Psychology, Pontifical Catholic University of Rio de Janeiro RJ - Brazil
| | - Heloisa Alves
- PhD, Department of Psychology, Pontifical Catholic University of Rio de Janeiro RJ - Brazil
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Shua-Haim J, Koppuzha G, Shua-Haim V, Gross J. A simple score system for clock drawing in patients with Alzheimer's disease. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153331759701200505] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To develop a simple clock drawing score system for patients with Alzheimer's disease, that correlates with the MMSE (Folstein Mini Mental Status Examination).1 Design: A retrospective analysis of 88 patients with the diagnosis of Alzheimer's disease Setting: Outpatient Memory Disorder Institute of a large community teaching hospital. Measurements: MMSE score and two different clock drawing ratings. The MMSE and the clock drawing scoring were performed by different raters. We present a “simple clock scoring system” and compared it with a previously published scoring system by Sunderland et al,2 referred to as the standard score system. Results: There is a strong correlation between the “new score system” and the standard scoring (Pearsons Correlation Coefficient r = 0.91, p < 0.001). However, when both systems were evaluated in a multivariate linear regression analysis, the “ simple score system “ was a significant predictor of Folstein MMSE (P < 0.01), while the standard scoring system was not. Conclusion: The “simple score system” is an easy to use, accurate predictor of the MMSE score, in patients with the diagnosis of Alzheimer's disease.
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Affiliation(s)
- Joshua Shua-Haim
- MedWise Center, Jersey Shore Medical Center and The Medical Center of Ocean County, New Jersey; UMONJ-SOM, Centerfor Aging, Stratford, New Jersey
| | | | | | - Joel Gross
- MedWise Center, Affiliated with Jersey Shore Medical Center and The Medical Center of Ocean County, New Jersey
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10
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Mainland BJ, Amodeo S, Shulman KI. Multiple clock drawing scoring systems: simpler is better. Int J Geriatr Psychiatry 2014; 29:127-36. [PMID: 23765914 DOI: 10.1002/gps.3992] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 05/06/2013] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Brian J Mainland
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
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11
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Use of the Freund Clock Drawing Test within the Mini-Cog as a screening tool for cognitive impairment in elderly patients with or without cancer. J Geriatr Oncol 2013; 4:174-82. [DOI: 10.1016/j.jgo.2012.10.175] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 06/29/2012] [Accepted: 10/05/2012] [Indexed: 11/20/2022]
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Abstract
The Clock Drawing Test (CDT) has been recognized as an effective tool for dementia detection. This study investigated the clock drawing performance of 240 non-demented elderly Korean people with a wide-range of educational levels and 28 patients with mild dementia of the Alzheimer's type (DAT). We examined the effects of demographic factors, including education, and established norms for the elderly population. We found that the educational attainment and literacy status of older people influenced performance on the CDT significantly (p < .001). Furthermore, qualitative error analysis revealed that normal participants with low educational background committed errors similar to errors of the DAT patients. The DAT patients performed significantly worse than the non-demented participants in the CDT Total score (p < .001). However, the CDT has better criterion validity in participants with more than 6 years of education. In conclusion, the CDT performance in older people who are either illiterate or with 6 or less years of education should be interpreted with caution. Conceptual errors in the CDT can be the result of not only dementia but also lack of education.
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13
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Nair AK, Gavett BE, Damman M, Dekker W, Green RC, Mandel A, Auerbach S, Steinberg E, Hubbard EJ, Jefferson A, Stern RA. Clock drawing test ratings by dementia specialists: interrater reliability and diagnostic accuracy. J Neuropsychiatry Clin Neurosci 2010; 22:85-92. [PMID: 20160214 PMCID: PMC2938787 DOI: 10.1176/jnp.2010.22.1.85] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The authors conducted a study of clock drawing test scoring by dementia specialists to determine interrater reliability and diagnostic accuracy. The authors randomly assigned 25 clocks from each of six predetermined groups based on consensus diagnosis (cognitive comparison subjects, subjects with a memory complaint but with normal neuropsychological testing, subjects with probable and possible mild cognitive impairment, and subjects with possible and probable Alzheimer's disease) to dementia specialists for blinded scoring using a binary yes/no impairment system and a 0-10 scale as subjectively determined by each individual clinician rater. The authors collapsed the six groups into three (comparison subjects, mild cognitive impairment patients, and Alzheimer's disease patients) and analyzed interrater reliability, sensitivity, and specificity for consensus diagnosis of mild cognitive impairment and Alzheimer's disease. The authors found excellent interrater reliability, sensitivity, and specificity for predicting consensus diagnosis. The 0-10 clock drawing test rating scale was more predictive of consensus diagnosis than the binary impairment scale. Based on rating systems, clock drawing test scoring by dementia clinicians had excellent interrater reliability and sensitivity for differentiating the mild Alzheimer's disease subjects from comparison subjects.
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Affiliation(s)
- Anil K Nair
- Alzheimer's Disease Center, Boston University School of Medicine, Boston, USA.
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Abstract
BACKGROUND The objective of this study was to review available dementia screening instruments that could be recommended for self-administration, particularly in electronic format. Owing to the gradual loss of insight associated with the progression of dementia, a broad definition of self-administration including self-administration by concerned informants (family, friends, carers) was used. METHOD A systematic search of PubMed, PsychINFO, and the Cochrane Library Database was conducted. Only available full-text articles about dementia screening instruments written in English were included. Articles reporting on instruments used in a non-English context were excluded unless a validated English version of the instrument was available. Included instruments were assessed against the precise criteria and characteristics of the Mini-mental State Examination (MMSE), the most widely used screening instrument. RESULTS The Concord Informant Dementia Scale (CIDS) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were the only instruments meeting all selection criteria. The Memory Impairment Screen (MIS) also met the criteria, although it lacks validation for self-administration. No instrument has been validated for self-administration in electronic format. CONCLUSIONS It is recommended that the MIS, the CIDS and the IQCODE be validated for self-administration in electronic format.
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Bo M, Massaia M, Speme S, Cappa G, Strumia K, Cerrato P, Ponzio F, Molaschi M. Cognitive function after carotid endarterectomy: greater risk of decline in symptomatic patients with left internal carotid artery disease. J Stroke Cerebrovasc Dis 2008; 14:221-8. [PMID: 17904030 DOI: 10.1016/j.jstrokecerebrovasdis.2005.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2005] [Accepted: 06/30/2005] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The risk of cognitive decline in patients undergoing carotid endarterectomy (CE) for left internal carotid artery (ICA) (LICA) disease before or after the occurrence of ischemic symptoms has not been fully elucidated. We evaluated whether patients undergoing CE for symptomatic LICA stenosis have greater risk of cognitive decline than patients with asymptomatic LICA disease or right ICA disease. METHODS In a series of patients aged 65 years and older, consecutively undergoing CE and free from cognitive impairment, cognitive function was evaluated through the age- and education-adjusted Mini Mental State Examination and the Clock Drawing Task at baseline and at the end of the study period (average follow-up: 44.4 +/- 14.3 months). RESULTS The analysis included 103 patients (mean age 72.6 +/- 7.0 years; 73 men), of whom 50 had LICA disease (29 symptomatic). At the end of the study period, Mini Mental State Examination score was reduced in patients with symptomatic LICA disease (P < .001) but not in other patients, whereas the Clock Drawing Task score was reduced in both patients with LICA and right ICA. Patients with symptomatic LICA disease had greater risk of cognitive decline than other individuals, either measured by the Mini Mental State Examination score (F = 5.18, P = .002) or by the Clock Drawing Task score (F = 9.42, P = .001). CONCLUSIONS Patients undergoing CE for symptomatic LICA disease appear to be at increased risk of cognitive decline than other individuals. Further studies are needed to confirm these findings and to evaluate whether LICA endarterectomy before occurrence of cerebrovascular ischemic symptoms may provide additive benefit in the prevention of cognitive decline.
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Affiliation(s)
- Mario Bo
- Section of Gerontology, Department of Medical and Surgical Disciplines, University of Turin, Turin, Italy
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Sensitivity and Specificity of the Assessment of Driving-related Skills Older Driver Screening Tool. TOPICS IN GERIATRIC REHABILITATION 2006. [DOI: 10.1097/00013614-200604000-00006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cacho J, García-García R, Fernández-Calvo B, Gamazo S, Rodríguez-Pérez R, Almeida A, Contador I. Improvement pattern in the clock drawing test in early Alzheimer's disease. Eur Neurol 2005; 53:140-5. [PMID: 15900096 DOI: 10.1159/000085832] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2004] [Accepted: 03/09/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this paper was to compare the performance of a group of patients with early Alzheimer's disease (EAD) against a control group of healthy control (HC) subjects in the Clock Drawing Test (CDT), i.e. verbal command versus copying of a clock model presented to the subject. PATIENTS AND METHODS The authors have studied 140 subjects; 70 patients with probable EAD, with a mean age of 76.4 +/- 7.64 years and a clinical dementia rating stage 1 (mild dementia), and 70 HC with a mean age of 75.16 +/- 6.34 years. RESULTS Patients in the EAD group obtained significantly higher scores on the copy command mode than on the verbal command mode (Z = -7.129, p < 0.001)--improvement pattern of the CDT--whereas no statistically significant differences were found in the HC group (Z = -2.001, p < 0.080). Within the group of EAD patients, we have noticed that there is a correlation between the copy command mode and the visual-constructive functions of the Cambridge Cognitive Examination (CAMCOG) (r = 0.607, p < 0.01), while the memory functions of the CAMCOG correlate with the verbal command mode (r = 0.704, p < 0.01). CONCLUSIONS In our study, the EAD patients show an improvement pattern in the execution of the CDT copy command in comparison with the execution of the CDT verbal command, which we did not observe in the HC group. Such results might be associated with a greater deterioration of the memory functions when compared with the visual-constructive ones in the patients with EAD.
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Affiliation(s)
- Jesús Cacho
- Section of Neurology, Salamanca University Hospital, Salamanca, Spain.
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Koch HJ, Gürtler K, Szecsey A. Correlation of Mini-Mental-State-Examination (MMSE), Syndrom-Kurztest (SKT) and Clock test (CT) scores in patients with cognitive impairment assessed by means of multiple regression and response surface analysis. Arch Gerontol Geriatr 2005; 40:7-14. [PMID: 15531019 DOI: 10.1016/j.archger.2004.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2003] [Revised: 04/29/2004] [Accepted: 05/13/2004] [Indexed: 10/26/2022]
Abstract
The objective of our study was to assess the correlation of routine neuropsychological test results in elderly patients referred to a gerontopsychiatric ward. MMSEs, CTs and SKTs were performed in 94 patients (age: median = 74 years, range = 54-89 years; 64 f, 30 m) with mild to moderate dementia and evaluated retrospectively. Pairwise Spearman rank correlation, multiple regression and response surface analysis were used to assess relations between test results. The scores of all three tests used were reciprocally correlated (P < 0.05) yielding the following pairwise R-values: SKT versus MMSE: -0.77, SKT versus CT: 0.69, MMSE versus Clock test: -0.61. Multiple regression analysis showed a maximum correlation of 0.87 and marked standardised beta values, if SKT was chosen as dependent variable. Test scores could be well fitted to both symmetric linear (SKT = a + b x CT + c x MMSE; R(2) = 0.67, P < 0.01) and non-linear (SKT = a + b x CT + c x MMSE + d x CT(2) + e x MMSE(2) + f x CT x MMSE; R(2) = 0.67, P < 0.01) response surfaces. In conclusion, test scores of SKT, CT or MMSE in patients with dementia showed a marked correlation. In clinical practice the may be considered as almost interchangeable test options.
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Affiliation(s)
- Horst J Koch
- Department of Gerontopsychiatry, University Clinic of Psychiatry, Universitätsstrasse 84, D-93053 Regensburg, Germany.
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Bunt R, Lipski PS. Driving and dementia: a prospective audit of clients referred to an aged care assessment team. Australas J Ageing 2003. [DOI: 10.1111/j.1741-6612.2003.tb00502.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fuzikawa C, Lima-Costa MF, Uchoa E, Barreto SM, Shulman K. A population based study on the intra and inter-rater reliability of the clock drawing test in Brazil: the Bambuí Health and Ageing Study. Int J Geriatr Psychiatry 2003; 18:450-6. [PMID: 12766923 DOI: 10.1002/gps.863] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Reliability should be considered when selecting a scoring system since it influences validity. CDT reliability has rarely been assessed in population based studies and in developing countries. The aim of the present study was to determine intra and inter-rater reliabilities of the CDT scored by the Shulman (2000) method, in elderly with very low formal educational level from Brazil. METHODS CDTs performed by a random sample of 202 subjects of a population-based cohort of elderly were scored on two occasions by the same rater and by two independent raters. Reliability was measured using the kappa statistic, weighted kappa and the intraclass correlation coefficient. Data were stratified according to gender, age and schooling level. RESULTS Intra and inter-rater reliabilities were excellent when CDTs were classified as 'normal' (scores 4 or 5) or 'abnormal' (scores 0 to 3) (kappa = 0.99 and 0.94, respectively) and were in the good to excellent range when scored from 0 to 5 (kappa = 0.88 and 0.74, respectively). Difficulties in distinguishing between scores 4 and 5, and a low proportion of score 1 tests were found. CONCLUSIONS The CDT scored by the Shulman (2000) method appears to have good to excellent reliability in an elderly population with very low formal educational level. However, difficulties in distinguishing between scores 4 and 5, and a low proportion of score 1 tests suggest these scores may not be totally adequate for this population. Further studies are necessary to determine the consistency of our results in similar populations.
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Affiliation(s)
- Cíntia Fuzikawa
- Public Health and Ageing Research Group (PHARG), Federal University of Minas Gerais Medical School and Oswaldo Cruz Foundation, René Rachou Research Institute, Belo Horizonte, Brazil.
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Juby A, Tench S, Baker V. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score. CMAJ 2002; 167:859-64. [PMID: 12406943 PMCID: PMC128397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND Executive cognitive dysfunction can precede the memory disturbances of dementia. People with executive cognitive dysfunction can have a normal Mini-Mental State Examination (MMSE) score but still have severe functional limitations. We evaluated the usefulness of clock drawing in identifying people with executive dysfunction who have a normal MMSE score. METHODS We reviewed the charts of consecutive patients referred between July 1999 and June 2000 to a multidisciplinary geriatric assessment clinic because of concerns about functional inabilities. The patients had all undergone the Executive Interview for the diagnosis of executive cognitive dysfunction as well as an MMSE and clock-drawing test (scored by 2 methods: one described by Watson and colleagues [the Watson method] and one described by Sunderland and colleagues [the Sunderland method]). RESULTS We reviewed the charts of 68 patients (40 women, 28 men); their mean age was 79 years (range 55-94). Thirty-six patients had an MMSE score of less than 24, and 32 had a "normal" MMSE score (24-30). Among those with a normal MMSE score, 22 had an abnormal Executive Interview score. Using the Executive Interview as the gold standard, the sensitivity and specificity of the Watson method of scoring clock drawings to predict an abnormal Executive Interview score were 59% and 70% respectively; the corresponding values were 18% and 100% for the Sunderland method. INTERPRETATION The presence of an abnormal MMSE score alerts clinicians to the possibility of cognitive impairment. For patients referred for geriatric assessment who have a normal MMSE score, a clock-drawing test, scored by either the Watson or the Sunderland method, is a moderately sensitive and specific adjunct for detecting executive cognitive dysfunction.
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Affiliation(s)
- Angela Juby
- Department of Medicine, University of Alberta, Edmonton.
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Heinik J, Solomesh I, Raikher B, Lin R. Can clock drawing test help to differentiate between dementia of the Alzheimer's type and vascular dementia? A preliminary study. Int J Geriatr Psychiatry 2002; 17:699-703. [PMID: 12211117 DOI: 10.1002/gps.678] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES the purpose of this preliminary study was to determine if clock drawing performance may help to differentiate between dementia of the Alzheimer's type (DAT) and vascular dementia (VD) patients. METHODS eighty-eight community-dwelling outpatients were comprehensively evaluated and met DSM-IV criteria for DAT or VD. Cognitive evaluation included the Mini-Mental State Examination (MMSE) and the Cambridge Cognitive Examination (CAMCOG). CAMCOG derived clock drawings were blindly evaluated by the same investigator, according to Freedman's method for clock drawing, and a total score as well as subscores (contour, numbers, hands and center) were determined. RESULTS There were no significant differences between DAT and VD patients in terms of demographic (age, gender, education) and cognitive (MMSE score, CAMCOG score) characteristics. On the average, the VD group showed slightly poorer performance on each of the clock drawing test (CDT) measures studied. With application of the Bonferroni correction, only Freedman's total score and hands subscore were statistically different between groups (p<0.003, p<0.004, respectively). Stepwise logistic regression analyses showed that the only significant variable was Freedman's total score (B=-0.273, p=0.005). Stepwise discriminant analysis identified Freedman's total score as the only significant predictor of diagnosis (Wilkes' lambda=0.903, p=0.003). This model correctly classified 65.9% overall into the respective DAT and VD groups. CONCLUSIONS CDT scored according to a comprehensive technique may be of value in differentiating DAT from VD patients. We hypothesize that the classificatory ability of Freedman's method might be attributed to its presumed sensitivity to impaired executive functioning which is more pronounced in VD compared with DAT patients.
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Affiliation(s)
- Jeremia Heinik
- Margoletz Psychogeriatric Center, Ichilov Hospital, Tel-Aviv, Israel.
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Lipski PS. A survey of general practitioners' attitudes to older drivers on the New South Wales Central Coast. Australas J Ageing 2002. [DOI: 10.1111/j.1741-6612.2002.tb00425.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kitabayashi Y, Ueda H, Narumoto J, Nakamura K, Kita H, Fukui K. Qualitative analyses of clock drawings in Alzheimer's disease and vascular dementia. Psychiatry Clin Neurosci 2001; 55:485-91. [PMID: 11555344 DOI: 10.1046/j.1440-1819.2001.00894.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although quantitative analyses of clock drawings (CD) have achieved widespread clinical use as a cognitive screening, little is known about the qualitative profiles of CD in Alzheimer's disease (AD) and vascular dementia (VD). To address this issue, the present study examined the significance of qualitative analyses of CD in AD and VD. Sixty-seven AD patients, 44 VD patients and eight controls underwent a clock drawing test and took the Mini-Mental State Examinations (MMSE). In the dementia groups, quantitative scores significantly decreased compared with controls and were significantly correlated with MMSE scores. Qualitative analysis demonstrated that in AD patients qualitative error patterns were stable and independent of severity. In contrast, in VD patients the frequency of graphic difficulties and conceptual deficit increased, while the frequency of spatial and/or planning deficit decreased, as severity worsened. In mild dementia groups the frequency of spatial and/or planning deficit was significantly higher in VD. In moderate dementia groups, the frequency of graphic difficulties was significantly higher in VD and the difference in the frequency of spatial and/or planning deficit seen in mild dementia disappeared. The present study suggests that qualitative analyses of clock drawings could demonstrate the neuropsychological profiles of AD and VD and their differences between these dementias.
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Affiliation(s)
- Y Kitabayashi
- Department of Psychiatry, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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Ruchinskas RA, Singer HK, Repetz NK. Clock drawing, clock copying, and physical abilities in geriatric rehabilitation. Arch Phys Med Rehabil 2001; 82:920-4. [PMID: 11441378 DOI: 10.1053/apmr.2001.23993] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine whether clock drawing and clock copying assess domains that are critical for successful rehabilitation and to evaluate the use of these tasks in predicting physical abilities during rehabilitation. DESIGN Observational survey study of geriatric cohorts. SETTING Inpatient university hospital rehabilitation unit. PATIENTS A total of 172 urban geriatric rehabilitation patients with orthopedic, neurologic, or medical diagnoses. MAIN OUTCOME MEASURES Clock drawing and copying, FIM instrument, Mattis Dementia Rating Scale, and Neurobehavioral Cognitive Status Examination. RESULTS Clock drawing and copying correlated highly with other measures of general cognitive ability. Classifying patients according to established cutoffs on clock drawing and copying revealed that patients with cognitive impairment had poorer physical abilities at discharge. CONCLUSION Clock drawing can be used as a brief screening measure to determine cognitive integrity. Clock copying can yield valuable information about geriatric patients' potential acute rehabilitation course and discharge status.
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Affiliation(s)
- R A Ruchinskas
- Department of Physical Medicine and Rehabilitation, Temple University Hospital, Philadelphia, PA, USA
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Abstract
OBJECTIVE To test the hypothesis that performance on a clock-drawing test in a mailed survey to an older cohort is associated with known and potential risk and protective factors for Alzheimer's disease. DESIGN The Leisure World Cohort Study is an ongoing study, begun in 1981, of nearly 14,000 older adults. In November 1992, the 8,406 living cohort members were mailed a follow-up questionnaire. SETTING Leisure World Laguna Hills, a southern California retirement community. PARTICIPANTS The study population is a predominantly white, well-educated, upper-middle-class community; approximately two-thirds are women. Data from 4,843 cohort members (mean age 80 years; range 52-101) were analyzed. MEASUREMENTS The questionnaire included a clock-drawing task: a predrawn circle 3 1/4 inches (8.3 cm) in diameter was provided with instructions "In the circle below, draw in the numbers as on a clock face. Make no erasures." Clocks were scored on 7 items: all numbers 1-12 present without adding extra or omitting numbers, sequencing of numbers, position of numbers, orientation of numbers to circle, consistent number style (either Arabic or Roman), tilt of numbers, and superfluous marks. A total clock score was calculated by summing the number of correct individual items (0-7). We also classified individuals as cognitively impaired by a previously suggested method: individuals were affected if they did not have three numbers drawn in the upper left quadrant of the clock face. RESULTS Ninety percent or more of the participants across all ages placed the numbers 1 to 12 on their clocks without omissions or additions; 35% completed the clock drawing without error. The mean total clock scores decreased with each successive 5-year age group in both men and women. Regression analysis indicated a significant effect for age (b = -0.15, P <.0001), education (b = 0.05, P =.0001), smoking (b = 0.13, P =.03), and female gender (b = -0.05, P =.05) and a marginally significant effect of nonrheumatoid arthritis (b = 0.05, P =.07) on total clock score. No other measured variable had a significant effect. Cognitively impaired individuals were more likely to be female and older. After adjusting for age and gender, they were also more likely to be hypertensive and to have taken blood pressure medication and less likely to be college graduates, have glaucoma or arthritis, and to have taken vitamin supplements. CONCLUSION The clock-drawing task is an appealing measure of cognitive function for large epidemiological studies because it is a simple, self-administered test that is easily adapted to mail surveys and correlates with more-detailed and more-time-consuming cognitive screens. Although it is relatively free of influence by language, cultural, or ethnic factors, our study shows that even in a highly educated population, clock drawing is influenced by educational level and other known risk factors for Alzheimer's disease. Thus a clock-drawing task may help predict cognitive frailty and future disability in older people. Such determination can direct high-risk individuals to earlier diagnosis, potential therapies, and better management.
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Affiliation(s)
- A Paganini-Hill
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Abstract
BACKGROUND As elderly populations grow, dementia detection in the community is increasingly needed. Existing screens are largely unused because of time and training requirements. We developed the Mini-Cog, a brief dementia screen with high sensitivity, specificity, and acceptability. Here we describe the development of its scoring algorithm, its receiver operating characteristics (ROC), and the generalizability of its clock drawing scoring system. SAMPLE AND METHODS A total of 249 multi-lingual older adults were examined. Scores on the three-item recall task and the clock drawing task (CDT-CERAD version) were combined to create an optimal algorithm. Receiver operating characteristics for seven alternatives were compared with those of the MMSE and the CASI using expert raters. To assess the CDT scoring generalizability, 20 naïve raters, without explicit instructions or prior CDT exposure, scored 80 randomly selected clocks as "normal" or "abnormal" (20 from each of four CERAD categories). RESULTS An algorithm maximizing sensitivity and correct diagnosis was defined. Its ROC compared favorably with those of the MMSE and CASI. CDT concordance between naïve and trained raters was >98% for normal, moderately and severely impaired clocks, but lower (60%) for mildly impaired clocks. Recalculation of the Mini-Cog's performance, assuming that naïve raters would score all mildly impaired CDTs in the full sample as normal, retained high sensitivity (97%) and specificity (95%). CONCLUSION The Mini-Cog algorithm performs well with simple clock scoring techniques. The results suggest that the Mini-Cog may be used successfully by relatively untrained raters as a first-stage dementia screen. Further research is needed to characterize the Mini-Cog's utility when population dementia prevalences are low.
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Affiliation(s)
- J Scanlan
- Alzheimer's Disease Research Center, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195-6560, USA.
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Heinik J, Reider-Groswasser II, Solomesh I, Segev Y, Bleich A. Clock drawing test: correlation with linear measurements of CT studies in demented patients. Int J Geriatr Psychiatry 2000; 15:1130-7. [PMID: 11180470 DOI: 10.1002/1099-1166(200012)15:12<1130::aid-gps259>3.0.co;2-n] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate a presumed correlation between clock drawing ratings and linear measurements of computerized tomography (CT) studies in demented patients. DESIGN Blinded evaluations of clock drawing tests and CT studies of elderly dementia patients were conducted by a geriatric psychiatrist and a neuroradiologist. SUBJECTS Fifty-one community-dwelling elderly subjects meeting the criteria for DSM-IV diagnosis of dementia (Alzheimer's type dementia: N=31; vascular dementia: N=15; "mixed" type dementia: N=5). MATERIALS Mini-Mental State Examination (MMSE), Cambridge Cognitive Examination (CAMCOG), Clinical Dementia Rating (CDR). CAMCOG derived scored clock drawings were evaluated using adaptations of Shulman et al.'s and Freedman et al.'s methods. CT studies were evaluated using six different linear measurements of brain atrophy described in the literature. RESULTS Of the CT linear measurements, only the Cerebro-Ventricular Index-2 (CVI-2; bicaudate index) significantly correlated with clock drawing ratings (CAMCOG's clock r=-0.407, p=0.003; Shulman's method r=0.357, p=0.01, Freedman's method r=-0.413, p=0.003) in the dementia group. There was no significant correlation between CVI-2 with demographic (age), cognitive (MMSE, CAMCOG) and clinical (duration of illness, CDR) ratings. Alzheimer's patients generally maintained a significant correlation between CVI-2 and clock drawings, but vascular dementia patients did not; CVI-2 also correlated significantly with the Praxis subtest of the CAMCOG in dementia and Alzheimer's patients but not in the vascular dementia group. Similarly, multiple stepwise regression analysis showed that only CVI-2 but not the other radiological measures studied, was selected as the significant variable to correlated with clock drawing test ratings in the dementia group and Alzheimer's patients. Partial correlation analysis controlling for demographic and clinical variables shows that controlled variables had no significant effect on the relationship between clock drawing ratings and CVI-2. CONCLUSION A single and easy to perform measure of caudate atrophy correlates specifically and consistently with impairments revealed in the clock drawing test and with a Praxis subtest, suggesting possible caudate involvement with clock drawings in dementia in general and of the Alzheimer's type in particular.
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Affiliation(s)
- J Heinik
- Margoletz Psychogeriatric Center, Ichilov Hospital, 6 Weizman Street, Tel-Aviv, Israel
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Position Statement No. 8 Geriatric Assessment and Community Practice. Australas J Ageing 2000. [DOI: 10.1111/j.1741-6612.2000.tb00230.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15:1021-7. [PMID: 11113982 DOI: 10.1002/1099-1166(200011)15:11<1021::aid-gps234>3.0.co;2-6] [Citation(s) in RCA: 967] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The Mini-Cog, a composite of three-item recall and clock drawing, was developed as a brief test for discriminating demented from non-demented persons in a community sample of culturally, linguistically, and educationally heterogeneous older adults. SUBJECTS All 129 who met criteria for probable dementia based on informant interviews and 120 with no history of cognitive decline were included; 124 were non-English speakers. METHODS Sensitivity, specificity, and diagnostic value of the Mini-Cog were compared with those of the Mini-Mental State Exam (MMSE) and Cognitive Abilities Screening Instrument (CASI). RESULTS The Mini-Cog had the highest sensitivity (99%) and correctly classified the greatest percentage (96%) of subjects. Moreover, its diagnostic value was not influenced by education or language, while that of the CASI was adversely influenced by low education, and both education and language compromised the diagnostic value of the MMSE. Administration time for the Mini-Cog was 3 minutes vs 7 minutes for the MMSE. CONCLUSIONS The Mini-Cog required minimal language interpretation and training to administer, and no test forms of scoring modifications were needed to compensate for the extensive linguistic and educational heterogeneity of the sample. Validation in clinical and population-based samples is warranted, as its brevity and ease of administration suggest that the Mini-Cog might be readily incorporated into general practice and senior care settings as a routine 'cognitive vital signs' measure.
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Affiliation(s)
- S Borson
- Alzheimer's Disease Research Center, University of Washington, Seattle, WA 98195-6560, USA.
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Abstract
OBJECTIVE The clock-drawing test has achieved widespread clinical use in recent years as a cognitive screening instrument and a significant amount of literature relates to its psychometric properties and clinical utility. This review aims to synthesize the available evidence and assess the value of this screening test according to well-defined criteria. DESIGN A Medline and Psycho-info literature search of all languages was done from 1983 to 1998 including manual cross-referencing of bibliographies. A brief summary of all original scoring systems is provided as well as a review of replication studies. Psychometric data including correlations with other cognitive tests were recorded. Qualitative aspects of the test are also described. RESULTS Among published studies, the mean sensitivity (85%) and specificity (85%) of the clock-drawing test are impressive. Correlations with the Mini-Mental State Examination and other cognitive tests was high, generally greater than r = 0.5. High levels of inter-rater and test-re-test reliability and positive predictive value are recorded and despite significant variability in the scoring systems, all report similar psychometric properties. The clock test also shows a sensitivity to cognitive change with good predictive validity. CONCLUSIONS The clock-drawing test meets defined criteria for a cognitive screening instrument. It taps into a wide range of cognitive abilities including executive functions, is quick and easy to administer and score with excellent acceptability by subjects. Together with informant reports, the clock-drawing test is complementary to the widely used and validated Mini-Mental State Examination and should provide a significant advance in the early detection of dementia and in monitoring cognitive change. A simple scoring system with emphasis on the qualitative aspects of clock-drawing should maximize its utility.
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Affiliation(s)
- K I Shulman
- Department of Psychiatry, University of Toronto, Sunnybrook & Women's College Health Sciences Centre, Ontario, Canada.
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Juby A. Correlation between the Folstein Mini-Mental State Examination and three methods of clock drawing scoring. J Geriatr Psychiatry Neurol 1999; 12:87-91. [PMID: 10483931 DOI: 10.1177/089198879901200209] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The objective of this study was to assess the correlation between (1) the Folstein Mini-Mental State Examination (MMSE) score and three methods of clock drawing scoring and (2) three methods of clock drawing scoring themselves. A convenience sample of consecutive community-dwelling seniors and attendees at a referral seniors clinic in a tertiary care hospital was used. One hundred fifty participants (72 women, 78 men) were seen with an average age of 76 years. There was a significant correlation (P = .01) between MMSE scores and all three methods of clock drawing (R = .67, .618, -.498, respectively), as well as among the three methods of clock drawing scoring. The clock drawing scores showed good correlation with the MMSE score. The clock drawing is well accepted (by the patient) and easily administered (by the health care provider). Clock drawings are recommended as the minimum requirement for cognitive assessment of elderly patients in busy primary care practices and can be used to highlight those patients requiring additional cognitive testing.
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Affiliation(s)
- A Juby
- Department of Medicine, University of Alberta, Edmonton
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Esteban-Santillan C, Praditsuwan R, Ueda H, Geldmacher DS. Clock drawing test in very mild Alzheimer's disease. J Am Geriatr Soc 1998; 46:1266-9. [PMID: 9777909 DOI: 10.1111/j.1532-5415.1998.tb04543.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The primary objective of this study was to determine the efficacy of the clock drawing test to predict the presence of very mild Alzheimer's disease (AD). A secondary objective was to identify elements of clock drawing that were most useful in differentiating cognitively intact older adults from those with mild Alzheimer's disease. DESIGN Cohort based comparison of retrospective data. SETTING Academic research center. PARTICIPANTS Clock drawings from 41 outpatient cases of mild AD with Mini-Mental State Exam scores of 24 or higher and 39 age- and education-matched older adults were scored. MEASUREMENTS Clock drawings were blindly and independently scored by two raters using the Clock Drawing Interpretation Scale and the scoring system reported by Rouleau et al. Predictive values for positive and negative tests were calculated using cut-off scores for total score and component subscores from each of these two systems. RESULTS Two or more errors in the depiction of the clock hands on the Clock Drawing Interpretation Scale had a positive predictive value for AD of 100% and a negative predictive value of 51%. A score of 2 or less on the 4-point hand-placement component of the Rouleau et al. scoring system provided a positive predictive value for AD of 94% and was associated with a negative predictive value of 62%. CONCLUSION An individual who commits two errors or more in drawing the clock hands deserves further investigation for a possible dementia. Normal hand placement on the clock drawing test does not exclude AD. However, when prevalence rates of dementia in community-dwelling older adults are considered, these results argue that normal clock hand placement indicates that dementia is unlikely.
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Affiliation(s)
- C Esteban-Santillan
- University Alzheimer Center, University Hospitals of Cleveland, Ohio 44120, USA
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Affiliation(s)
- P S Lipski
- Department of Geriatric Medicine, Gosford Hospital, NWS
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Abstract
Neglect is a disabling state in stroke patients. Five tests for visuo-spatial neglect, star cancellation, line crossing, line bisection, draw a clock and copy a cross, were compared in 57 elderly patients. Sensitivity and intercorrelations between the tests were determined. Patients with neglect were studied as regards their activities of daily living, motor activity and cognition. Left-hemisphere neglect in patients with right-hemisphere lesions was more severe than right-sided neglect in patients with left-sided lesions in the star cancellation test. Sensitivity of the tests was moderate for star cancellation, line bisection and draw a clock, and low for line crossing and copy a cross. Significant correlations existed between the tests and cognitive and functional ability. Intercorrelations between the tests were moderate. Neglect patients showed a slower recovery after 6 and 12 months. Draw a clock and a cross displayed no sensitivity for neglect in patients with hemianopia, which may be due to the fact that these tests also evaluate constructional apraxia. The cancellation tests were influenced by hemianopia and there is evidence that hemianopia exacerbates neglect. This study shows that a battery of neglect tests is required to diagnose the neglect syndrome.
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Affiliation(s)
- B M Agrell
- Department of Internal Medicine, Lund University Hospital, Sweden
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Bush C, Kozak J, Elmslie T. Screening for cognitive impairment in the elderly. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 1997; 43:1763-8. [PMID: 9356757 PMCID: PMC2255451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the extent and type of screening for cognitive impairment primary care physicians use for their elderly patients, to identify perceived barriers to screening, and to explore whether physicians would be willing to use the clock drawing test as a cognitive screening tool. DESIGN Mailed questionnaire. SETTING Primary care practices in the Ottawa-Carleton region. PARTICIPANTS Family physicians and general practitioners culled from the Yellow Pages and Canadian Medical Directory; 368 of 568 questionnaires were returned for a response rate of 70%. Six respondents had fewer than 30 patients weekly and two responded too late to be included in the analysis; 360 cases were included in the analysis. MAIN OUTCOME MEASURES Responses to 10 questions on cognitive screening and five on demographics and the nature of respondents' practices. RESULTS About 80% of respondents reported doing at least one mental status examination during the past year. Only 24% routinely screened patients, although 82% believed screening was needed. Major barriers to cognitive screening were lack of time, risk of offending patients, and possible negative consequences of follow up. Clock drawing was perceived as an acceptable method of screening, if it were proven effective. CONCLUSIONS Most primary care physicians believe cognitive screening is needed, but few routinely screen their elderly patients. Lack of time is the most important perceived barrier to screening. Primary care physicians are receptive to using the clock drawing test, and, because it is not time-consuming, are less likely to consider lack of time a barrier to testing. The clock test might help bridge the gap between perceived need for screening and actual screening.
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Ferrucci L, Cecchi F, Guralnik JM, Giampaoli S, Lo Noce C, Salani B, Bandinelli S, Baroni A. Does the Clock Drawing Test predict cognitive decline in older persons independent of the Mini-Mental State Examination? The FINE Study Group. Finland, Italy, The Netherlands Elderly. J Am Geriatr Soc 1996; 44:1326-31. [PMID: 8909348 DOI: 10.1111/j.1532-5415.1996.tb01403.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the value of the Clock Drawing Test (CDT) in predicting cognitive deterioration over a 4-year period, independent of baseline cognitive status evaluated by the Mini-Mental State Examination (MMSE). DESIGN A preplanned analysis of data collected during the second (1991) and the third (1995) follow-up of the Italian rural cohorts of the FINE Study (Finland, Italy, the Netherlands Elderly). SUBJECTS Of the 427 men (mean age 77.6 +/- 4.1 years; range 72-90 years) interviewed in 1991, 264 survived and were reinterviewed in 1995. The study population included 247 persons who were interviewed and received a complete cognitive evaluation in both 1991 and in 1995. MEASUREMENTS Cognitive assessment in 1991 included the MMSE, the Dementia Rating Scale (DRS), and the CDT. The CDT was classified as normal or pathological, based on previously established criteria. The MMSE and the DRS were repeated in 1995. RESULTS Independent of age and baseline MMSE, score, subjects with pathological CDT compared with normal CDT had lower MMSE scores at follow-up (P < .01). These results were also confirmed by evaluating cognitive decline through its impact on change over time in daily life autonomy, as measured by the DRS (P < .01). Among persons scoring more than 21 on the MMSE, compared with persons with a normal CDT, those with pathological CDT performance were 5.4 (95% CI: 2.1-14.2) and 5.5 (95% CI: 1.6-19.6) times more likely to have a MMSE score below 21 and 18, respectively, 4 years later, independent of age and baseline MMSE score. CONCLUSIONS Findings suggest that the CDT identifies older persons at high risk of cognitive decline and adds prognostic information that supplements the standard MMSE test.
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Affiliation(s)
- L Ferrucci
- Geriatric Department, I Fraticini, National Research Institute (INRCA), Florence, Italy.
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Abstract
OBJECTIVE To describe an approach to the diagnosis of dementia based on effective assessment methods. DESIGN We reviewed the literature and summarized the available diagnostic and prognostic studies of dementia that may be useful to the primary-care physician. RESULTS Although controversy exists about certain aspects of the diagnostic workup, exclusion of potentially reversible causes of dementia is essential. Laboratory studies (for example, for detection of underlying metabolic abnormalities) and neuroimaging of the brain may be useful. The pattern of onset and the temporal course of the disease may suggest a cause and help direct the investigation. Functional losses can substantially impair the patient's ability to live independently. CONCLUSION Dementia can be mistakenly considered as part of the normal aging process, and diagnosis necessitates a thorough, although not exhaustive, approach. Early identification of dementing illnesses improves the outcome for reversible disease and may also enhance the management of incurable dementias.
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Affiliation(s)
- K C Fleming
- Section of Geriatrics, Mayo Clinic Rochester, Minnesota 55905, USA
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Fleming KC, Evans JM, Weber DC, Chutka DS. Practical functional assessment of elderly persons: a primary-care approach. Mayo Clin Proc 1995; 70:890-910. [PMID: 7643645 DOI: 10.1016/s0025-6196(11)63949-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To describe simple, practical measures of physical and psychosocial function to detect problems and enhance the care of elderly patients. DESIGN We reviewed pertinent articles and current standard textbooks of geriatrics; the most useful findings are summarized, and tools that can be used for functional assessment of the geriatric population are presented. RESULTS Care of elderly patients necessitates a comprehensive review of key areas of function. Using only clinical judgment, physicians may overlook important clinical deficits common in older patients. Because of their length and complexity, many of the standard geriatric assessment tools are impractical for use by primary-care physicians. Certain simplified or condensed versions--such as the Functional Reach Test and the "Get Up and Go" Test--are efficient substitutes. In this article, we describe methods for practical identification of functional impairments, assessment of cognition and mood, evaluation of hearing and vision, and detection of problems with continence, nutrition, and social needs. Instruments for assessment of caregiver burden are also outlined. CONCLUSION Use of the assessment tools presented herein can assist primary-care physicians in comprehensive evaluation of function in older patients.
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Affiliation(s)
- K C Fleming
- Section of Geriatrics, Mayo Clinic Rochester, Minnesota 55905, USA
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Ben-Yehuda A, Bentur N, Friedman G. The clock drawing test as a cognitive screening tool for elderly patients in an acute-care hospital. AGING (MILAN, ITALY) 1995; 7:188-90. [PMID: 8547374 DOI: 10.1007/bf03324312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- A Ben-Yehuda
- Division of Medicine, Hadassah University Hospital, Ein Karem, Jerusalem, Israel
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