The clock drawing test is a poor screen for very mild dementia

Evaluating the feasibility of cognitive impairment detection in Alzheimer's disease screening using a computerized visual dynamic test

BACKGROUND

Alzheimer's disease (AD) is a neurodegenerative disease without known cure. However, early medical treatment can help control its progression and postpone intellectual decay. Since AD is preceded by a period of cognitive deterioration, the effective assessment of cognitive capabilities is crucial to develop reliable screening procedures. For this purpose, cognitive tests are extensively used to evaluate cognitive areas such as language, attention, or memory.

METHODS

In this work, we analyzed the potential of a visual dynamics evaluation, the rapid serial visual presentation task (RSVP), for the detection of cognitive impairment in AD. We compared this evaluation with two of the most extended brief cognitive tests applied in Spain: the Clock-drawing test (CDT) and the Phototest. For this purpose, we assessed a group of patients (mild AD and mild cognitive impairment) and controls, and we evaluated the ability of the three tests for the discrimination of the two groups.

RESULTS

The preliminary results obtained suggest the RSVP performance is statistically higher for the controls than for the patients (p-value = 0.013). Furthermore, we obtained promising classification results for this test (mean accuracy of 0.91 with 95% confidence interval 0.72, 0.97).

CONCLUSIONS

Since the RSVP is a computerized, auto-scored, and potentially self-administered brief test, it could contribute to speeding-up cognitive impairment screening and to reducing the associated costs. Furthermore, this evaluation could be combined with other tests to augment the efficiency of cognitive impairment screening protocols and to potentially monitor patients under medical treatment.

The clock drawing test is an important contribution to the Mini Mental State Examination in screening for cognitive impairment

BACKGROUND

The clock drawing test (CDT) and the Mini Mental State Examination (MMSE) are frequently used screening instruments for cognitive impairment, however, the precise contribution of the CDT to the MMSE is largely unknown.

METHODS

We studied patients with subjective cognitive impairment (SCI, n = 481), mild cognitive impairment (MCI, n = 628) and Alzheimer's disease (AD, n = 1099). Discrimination between patients was examined with multiple logistic regression, adjusted for age, sex, and education. Four groups were constructed based on a normal/abnormal MMSE (cut-off <24/30) versus normal/abnormal CDT (cut-off ≤2/3). Visually rated medial temporal lobe atrophy (MTA) on CT was used as parameter of neurodegeneration.

RESULTS

The CDT significantly contributed to the MMSE in discriminating SCI from both MCI and AD patients. Our four group analyses showed that of those patients with a normal MMSE and incorrectly classified as SCI, an abnormal CDT could significantly identify 10.0% as MCI and 13.2% as AD. Among those with an abnormal MMSE, the percentage AD patients shifted from 53.1% to 82.1% due to an abnormal CDT. Presence of an abnormal CDT was significantly related to MTA increase, regardless of the MMSE score.

CONCLUSION

The CDT is an important additional screening tool to the MMSE. An abnormal CDT with a normal MMSE is an indicator for cognitive impairment. An abnormal CDT in combination with an abnormal MMSE can be considered as an indicator of disease progression.

Explainable automated evaluation of the clock drawing task for memory impairment screening

Introduction

The clock drawing task (CDT) is frequently used to aid in detecting cognitive impairment, but current scoring techniques are time-consuming and miss relevant features, justifying the creation of an automated quantitative scoring approach.

Methods

We used computer vision methods to analyze the stored scanned images (N = 7,109), and an intelligent system was created to examine these files in a study of aging World Trade Center responders. Outcomes were CDT, Montreal Cognitive Assessment (MoCA) score, and incidence of mild cognitive impairment (MCI).

Results

The system accurately distinguished between previously scored CDTs in three CDT scoring categories: contour (accuracy = 92.2%), digits (accuracy = 89.1%), and clock hands (accuracy = 69.1%). The system reliably predicted MoCA score with CDT scores removed. Predictive analyses of the incidence of MCI at follow-up outperformed human-assigned CDT scores.

Discussion

We created an automated scoring method using scanned and stored CDTs that provided additional information that might not be considered in human scoring.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Edmonton frailty scale score predicts postoperative delirium: a retrospective cohort analysis

BACKGROUND

Frailty has been associated with postoperative delirium (POD). Studies suggest that the Fried phenotype has a stronger association with POD than the Edmonton Frailty Scale (EFS) criteria. Although phenotypic frailty is recognized as a good predictor of delirium, the EFS has higher ratings for feasibility in the surgical setting. Thus, our aim was to determine the association between EFS-assessed vulnerability and POD in an elective surgical population of older adults. A secondary aim was to determine which domains assessed by the EFS were closely associated with POD.

METHODS

After IRB approval was received, electronic medical records of surgical patients at our institution were downloaded from 12/1/2018 to 3/1/2020. Inclusion criteria included age ≥ 65 years, preoperative EFS assessment within 6 months of surgery, elective surgery not scheduled for intensive care unit (ICU) stay but followed by at least 1 day postoperative stay, and at least two in-hospital evaluations with the 4 A's test (arousal, attention, abbreviated mental test-4, acute change [4AT]) on the surgical ward. Vulnerability was determined by EFS score ≥ 6. Patients were stratified into two groups according to highest postoperative 4AT score: 0-3 (no POD) and ≥ 4 (POD). Odds of POD associated with EFS score ≥ 6 were evaluated by using logistic regression adjusted for potential confounders.

RESULTS

The dataset included 324 patients. Vulnerability was associated with higher incidence of POD (p = 0.0007, Fisher's exact). EFS ≥6 was consistently associated with POD in all bivariate models. Vulnerability predicted POD in multivariable modeling (OR = 3.5, 95% CI 1.1 to 11.5). Multivariable analysis of EFS domains revealed an overall trend in which higher scores per domain had a higher odds for POD. The strongest association occurred with presence of incontinence (OR = 3.8, 95% CI 1.2 to 11.0).

CONCLUSIONS

EFS criteria for vulnerability predict POD in older, non-ICU patients undergoing elective surgery.

Clock drawing test: comparison between the Pfizer and the Shulman systems

ABSTRACT Cognitive decline can be screened by the clock drawing test (CDT), which has several versions. Objective: This survey aimed to analyze the correlation between two simple methods for scoring the CDT. Methods: This cross-sectional study was nested in the Elo-Creati cohort from Passo Fundo, Brazil and comprised 404 subjects. Two raters underwent previous training and scored the subjects’ CDT according to both the Pfizer and Shulman systems. The inter-observer and intra-observer concordance within each method was analyzed with the Spearman’s rank correlation coefficient, as well as the concordance of the scores between the two methods. Age and scholarity were also correlated with the scores. Results: Most of the participants were women (93.8%) and Caucasian (84.6%), with a mean age of 66.9 (±7.8) years and a scholarity of 10.9 years (±5.6). There was significant inter-observer (Pfizer: r=0.739, p£0.001; Shulman: r=0.727, p£0.001) and intra-observer correlation (Pfizer: rater 1, r=0.628, p≤0.001; rater 2, r=0.821, p≤0.001; Shulman: rater 1, r=0.843, p≤0.001; rater 2: r=0.819; p≤0.001). Intra-observer correlation was also observed comparing Pfizer and Shulman methods (rater 1: r=0.744; p≤0.001; rater 2: r=0.702; p≤0.001). There was weak correlation of the scores with scholarity (Pfizer: r=0.283, p£0.001; Shulman: r=0.244, p£0.001) and age (Pfizer: r=-0.174, p£0.001; Shulman: r=-0.170, p£0.001). More participants were classified with decreased cognition through the Pfizer system (rater 1: 44.3 vs. 26.5%; rater 2: 42.1 vs. 16.3%; p≤0.001). Conclusions: For this population, our results suggest that the Pfizer system of scoring CDT is more suitable for screening cognitive decline.

Neurocognitive Changes in Spinocerebellar Ataxia Type 3: A Systematic Review with a Narrative Design

Spinocerebellar ataxia type 3 (SCA3), the commonest dominantly inherited ataxia worldwide, is characterized by disruption in the cerebellar-cerebral and striatal-cortical networks. Findings on SCA3-associated cognitive impairments are mixed. The classification models, tests and scoring systems used, language, culture, ataxia severity, and depressive symptoms are all potential confounders in neuropsychological assessments and may have contributed to the heterogeneity of the neurocognitive profile of SCA3. We conducted a systematic review of studies evaluating neurocognitive function in SCA3 patients. Of 1304 articles identified, 15 articles met the eligibility criteria. All articles were of excellent quality according to the National Institutes of Health quality assessment tool for case-control studies. In line with the disrupted cerebellar-cerebral and striatal-cortical networks in SCA3, this systematic review found that the neurocognitive profile of SCA3 is characterized by a core impairment of executive function that affects processes such as nonverbal reasoning, executive aspects of language, and recall. Conversely, neurocognitive domains such as general intelligence, verbal reasoning, semantic aspect of language, attention/processing speed, recognition, and visuospatial perception and construction are relatively preserved. This review highlights the importance of evaluating neurocognitive function in SCA3 patients. Considering the negative impact of cognitive and affective impairment on quality of life, this review points to the profound impairments that existing or future treatments should prioritize.

What is the contribution of executive functions to communicative-pragmatic skills? Insights from aging and different types of pragmatic inference

The role of executive functions in supporting the pragmatics of communication has been extensively examined in clinical populations, but is still under-explored in healthy aging. In this study we addressed the role of executive skills, including inhibition, working memory, and cognitive flexibility, in older adults' communicative-pragmatic abilities. Pragmatics was extensively assessed by measuring the understanding of figurative language, narrative texts, humor, and implicatures. A hierarchical regression analysis using composite scores evidenced a global effect of executive functions on communicative-pragmatic abilities, beyond demographic and theory of mind aspects. More fine-grained analyses showed that working memory was the strongest predictor of all pragmatic tasks. Specifically, comprehending narratives and humor seemed to capitalize primarily upon working memory, whereas figurative language and implicatures relied on working memory and to some extent cognitive flexibility. Conversely, inhibition did not stand out as a robust predictor of pragmatics. We argue that working memory allows for the simultaneous consideration of multiple pieces of information needed for pragmatic inferencing, and that only once working memory has played its role other executive aspects, such as cognitive flexibility and inhibition, might come into play. Overall, this study highlights the diverse role of executive skills in pragmatics in aging, and more generally contributes to shed light on pragmatic competence in older adults.

Comparison of Performance on the Clock Drawing Test Using Three Different Scales in Dialysis Patients

Background

The clock drawing test (CDT) is frequently used to detect changes in cognition. Multiple scales of varying length have been published to assess performance. The aim of this study is to compare the CDT performance measured by three scales among a sample of nondemented patients on renal dialysis and identify the variables that affect performance. Methodology. This is a cross-sectional study performed at the dialysis unit at King Saud University Medical City. Eighty-nine dialysis patients performed the CDT. The CDT was scored by the methods of Rouleau et al. (RCS 10-point), Babins et al. (BCS 18-point), and the MoCA (MCS 3-point). Regression models were used to determine influencing demographic and dialysis variables. Scores were then correlated, and a combined factor analysis of scale components was done.

Results

Females represented 44.6%, the mean (SD) age was 49.99 (15.49) years, and education duration was 10.29 (5.5) years. Dialysis vintage was 55.81 (62.91) months. The scores for the MCS, RCS, and BCS were 2.18 (1.08), 6.67 (3.07), and 11.8 (5.5), respectively, with significant correlation (P < 0.0001). In all scales, increasing age was associated with a lower score (each P < 0.0001). The scores increased with increasing education (each P < 0.0001). Diabetics had a lower score on both the BCS and MCS by 2.56 (SE 1.2) (P = 0.035) and 0.71 (P = 0.003) points, respectively. However, only age and years of education were significant in the multivariable analysis. In factor analysis, two shared factors appeared between the three scales: hand and number placement and the clock face.

Conclusion

Age and education influence the performance on the CDT, and factors diverged into executive and visuospatial components. The MCS is likely to yield useful information but should be interpreted as part of the MoCA.

Daily exposure to digital displays may affect the clock-drawing test: from psychometrics to serendipity

BACKGROUND

The clock-drawing test (CDT) is a neuropsychological screening tool largely used to explore cognitive functioning. It requires participants to draw an analog clock face. Many studies have reported a good correlation between the CDT and the Mini-Mental State Examination (MMSE). The CDT has also showed a variable specificity. There are, however, some inconsistencies concerning the effect of sociodemographic variables (sex, age, education) on clock-drawing abilities. The present study aimed at examining these issues in a sample of middle-aged/young-old healthy adults.

METHOD

Participants (n = 97) performed the MMSE and CDT. Clock drawings were assessed by five formal scoring systems (Wolf-Klein, Watson, Freedman, Manos, Shulman). In addition, three naïve raters provided a dichotomous judgment (normal vs. abnormal) for each clock.

RESULTS

Sociodemographic variables did not affect CDT performance. Unlike earlier studies, CDT scores did not correlate with MMSE. Moreover, test specificity was appropriate only for Freedman's, Shulman's, and Wolf-Klein's methods. Interestingly, some participants drew clocks with numbers as they appear in digital clocks. By re-running the statistical analyses after removing these atypical clocks, four out of the five formal scores showed a significant correlation with MMSE; furthermore, CDT specificity slightly increased for all scoring systems including naïve ratings.

CONCLUSIONS

CDT is not affected by sociodemographic variables. The finding of some clocks with digitally represented numbers suggests the need to align neuropsychological assessments with demands from an increasing digitalized environment. Moreover, the occurrence of high false-positives and possible digital contaminations suggest great caution in interpreting the clinical significance of CDT.

Serum levels of glial cell line-derived neurotrophic factor and multiple neurotransmitters: In relation to cognitive performance in Parkinson's disease with mild cognitive impairment

OBJECTIVES

Mild cognitive impairment is a common non-motor feature of Parkinson's disease, termed PD-MCI. But there is a scarcity of data on the role of glial cell line-derived neurotrophic factor (GDNF) and neurotransmitters in pathogenesis of PD-MCI. The aim of this project was to detect the serum levels of GDNF and multiple neurotranmitters and explore their relationships with cognitive performance in PD-MCI patients.

METHODS

Neuropsychological testing was administered to PD patients and healthy controls to investigate different domains of cognitive function. Serum levels of GDNF and four cognition-related neurotransmitters including Dopamine metabolites Homovanillic acid (HVA), acetylcholine (Ach), γ-aminobutyric acid (GABA) and 5-hydroxytryptamine (5-HT) were detected by enzyme-linked immunosorbent assay and liquid chromatography-electrospray ionization tandem mass spectrometry analysis respectively.

RESULTS

The more serious cognitive impairment of PD, the lower levels of GDNF, HVA and 5-HT. In PD-MCI patients, the levels of GDNF, HVA, Ach, 5-HT, and GABA had a significant positive correlation with Digit span backward test (DSB-T) scores and negative correlation with the scores of Trail Making Test A (TMT-A) and Trail Making Test B (TMT-B) respectively. Effect size analysis showed that GDNF and GDNF*Ach have a significant effect on DSB-T, TMT-A and TMT-B respectively; GDNF*HVA, GDNF*5-HT and GDNF*GABA play important part in Auditory Verbal Learning Test separately.

CONCLUSIONS

Serum GDNF may be involved in the impairment of attention, memory and executive function of PD-MCI patients, by acting alone or in conjunction with neurotransmitters (HVA, 5-HT, GABA, and Ach).

A comparison of six clock-drawing test scoring methods in a nursing home

BACKGROUND

Clock-drawing test (CDT) is widely used but lack of a suitable scoring method.

AIMS

To compare the validity of six common CDT scoring methods and to find out the best one.

METHODS

The drawing CDT was administered in a Chinese nursing-home inhabitants living on the mainland including 110 dementia, 118 MCI (mild cognitive impairment), and 133 random normal. We calculated the sensitivity and specificity of six scoring methods and applied the receiver-operating characteristic (ROC) curve statistic, including determining the area under the curve (AUC).

RESULTS

(1) All six CDT scoring methods had a value of sensitivity higher than 80% and a specificity of 60% except Jouk and Tuokko. Freund got the highest sensitivity (92.73%) of that five for the testing of dementia and high sensitivity (82.20%) for MCI with an acceptable specificity (70.68%). (2) The AUC (area under the ROC curve) of all six CDT methods was over 0.8 for dementia, and for MCI, only Jouk and Tuokko were lower than 0.8. Mendez had the largest AUC of 0.872 for MCI, which closely followed by Freund with 0.859. (3) Freund predicted dementia best but had no significant difference (p > 0.05); it only had significant difference with Jouk and Tuokko (p < 0.001) and the method in MoCA (p < 0.05) for both MCI and cognitive impairment.

CONCLUSIONS

Our study suggests that Freund scoring method could be the best one among the six evaluated scoring methods within our setting.

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

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

Early Detection of Mild Cognitive Impairment With In-Home Monitoring Sensor Technologies Using Functional Measures: A Systematic Review

The aging of the world population is accompanied by a substantial increase in neurodegenerative disorders, such as dementia. Early detection of mild cognitive impairment (MCI), a clinical diagnostic that comes with an increased chance to develop dementias, could be an essential condition for promoting quality of life and independent living, as it would provide a critical window for the implementation of early pharmacological and nonpharmacological interventions. This systematic review aims to investigate the current state of knowledge on the effectiveness of smart home sensors technologies for the early detection of MCI through the monitoring of everyday life activities. This approach offers many advantages, including the continuous measurement of functional abilities in ecological environments. A systematic search of publications in MEDLINE, EMBASE, and CINAHL, before November 2017, was conducted. Seventeen studies were included in this review. Thirteen studies were based on real-life monitoring, with several sensors installed in participants' actual homes, and four studies included scenario-based assessments, in which participants had to complete various tasks in a research lab apartment. In real-life monitoring, the most used indicators of MCI were walking speed and activity/motion in the house. In scenario-based assessment, time of completion, quality of activity completion, number of errors, amount of assistance needed, and task-irrelevant behaviors during the performance of everyday activities predicted MCI in participants. Despite technological limitations and the novelty of the field, smart home technologies represent a promising potential for the early screening of MCI and could support clinicians in geriatric care.

Cognitive impairment in Parkinson's disease, Alzheimer's dementia, and vascular dementia: the role of the clock-drawing test

AIM

Cognitive impairment is present in several neurodegenerative disorders. The clock-drawing test (CDT) represents a useful screening instrument for assessing the evolution of cognitive decline. The aim of this study was to investigate the sensitivity of the CDT in monitoring and differentiating the evolution of cognitive decline in Alzheimer's dementia (AD), vascular dementia (VaD), and Parkinson's disease (PD).

METHODS

This study involved 139 patients, including 39 patients with PD and mild cognitive impairment, 16 demented PD patients, 21 VaD patients with mild cognitive impairment, 17 patients with VaD, 33 patients with mild cognitive impairment due to AD, and 13 patients with probable AD. All participants completed the CDT. The Mini-Mental State Examination was administered to establish patients' cognitive functioning.

RESULTS

Comparisons of quantitative and qualitative CDT scores showed significant differences between the various diseases. Impairment of executive functioning seems to be more pronounced in PD and VaD than in AD. Patients with AD committed more errors related to a loss of semantic knowledge, indicating a severely reduced capacity in abstract and conceptual thinking.

CONCLUSION

Results support the usefulness and sensitivity of the CDT in the detection of different dementia subtypes. Qualitative error analysis of the CDT may be helpful in differentiating PD, VaD, and AD, even in the early stages of each disease.

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

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

Digitally translated Self-Administered Gerocognitive Examination (eSAGE): relationship with its validated paper version, neuropsychological evaluations, and clinical assessments

BACKGROUND

The original paper Self-Administered Gerocognitive Examination (SAGE) is a valid and reliable cognitive assessment tool used to identify individuals with mild cognitive impairment (MCI) or early dementia. We evaluated identical test questions in a digital format (eSAGE) made for tablet use with the goals of calibrating it against SAGE and establishing its association with other neuropsychological tests and clinical assessments of cognitive impairment.

METHODS

Subjects aged 50 and over who had taken SAGE were recruited from community and clinic settings. Subjects were randomly selected to participate in a clinical evaluation including neuropsychological evaluations. SAGE and eSAGE were administered using a crossover design. Subjects were identified as dementia, MCI, or normal based on standard clinical criteria. Associations were investigated using Spearman correlations, linear regression, and sensitivity and specificity measures.

RESULTS

Of the 426 subjects screened, 66 completed the evaluation. eSAGE score correlation to a battery of neuropsychological tests was 0.73 (p < 0.0001) with no significant difference between the paper and digital format. Spearman correlation of SAGE versus eSAGE was 0.88 (p < 0.0001), and they are related by the formula: eSAGE score = -1.05 + 0.99 × SAGE score. Since the slope is very close to 1 (p = 0.86) there is strong evidence that the scaling is identical between eSAGE and SAGE, with no scale bias. Overall, eSAGE scores are lower by an average of 1.21 and the decrease is statistically significant (p < 0.0001). For those subjects familiar with smartphones or tablets (one measure of digital proficiency), eSAGE scores are lower by an average of 0.83 points (p = 0.029). With a score 16 and higher being classified as normal, eSAGE had 90% specificity and 71% sensitivity in detecting those with cognitive impairment from normal subjects.

CONCLUSIONS

Tablet-based eSAGE shows a strong association with the validated paper SAGE and a neuropsychological battery. It shows no scale bias compared to SAGE. Both have the advantage of self-administration, brevity, four interchangeable forms, and high sensitivity and specificity in detecting cognitive impairment from normal subjects. Their potential widespread availability will be a major factor in overcoming the many obstacles in identifying early cognitive changes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02544074 . Registered on 18 March 2015.

Scoring systems for the Clock Drawing Test: A historical review

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

Living Alone With Cognitive Impairment

Although most individuals experiencing cognitive impairment (CI) reside with a caregiver, an estimated 800,000 live alone. Such individuals may have an increased risk for injury to self or others through self-neglect as a result of the CI symptoms. While persons living alone with CI have been identified as an important area for needed research, few studies have been able to examine this population due to the challenges of identifying and recruiting study participants. By using the National Health & Aging Trends Study data set, the researchers explored the characteristics to describe this population. The results of this study indicated that the majority of persons living with CI were older, widowed females who were not diagnosed with Alzheimer's or dementia but tested positive on cognitive screening measures. Further, the majority of persons living alone with CI relied on adult children and paid professionals as the primary care providers.

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

Purpose. To investigate the diagnostic accuracy of the overlapping infinity loops, wire cube, and clock drawing tests (CDT) in the detection of mild cognitive impairment (MCI) and dementia. Method. The participants were 60 normal controls (NC), 35 patients with MCI, and 47 patients with mild dementia. Results. The results illustrate that infinity loops, cube, or CDT were not able to discriminate between NC and MCI groups. In dementia detection, the CDT had the highest diagnostic accuracy (sensitivity 76.6% and specificity 87.4%) followed by infinity loops (sensitivity 63.8% and specificity 91.6%) and cube (sensitivity 93.6% and specificity 46.3%). Conclusion. This study demonstrates that the three drawing tests are sensitive detectors of dementia but not MCI.

Use of the Ten-Point Clock Test to Compare Executive Functioning across 24 Months in Patients with Subcortical Vascular Dementia

The Ten-point Clock Test can be used to identify early forms of Alzheimer's disease because it is reliable, well accepted, and easily administered at the bedside. Nevertheless, its clinical role in the detection of early dementia and its correlations with other cognitive processes is still under investigation. Vascular dementia is an uncertain nosological entity, in which unevenly distributed patterns of cognitive deficits comprising slowing of cognitive processing and impairment of executive function occur. The present study assessed how the Clock Test scores correlated with a number of other neuropsychological and functional tests in a sample of 144 patients with vascular dementia, who were followed for a period of 24 mo. At baseline, at 12 mo. and at 24 mo. subjects were administered a battery of tests, including the Mini-Mental State Examination, word fluency, visuospatial skills, an evaluation of hetero- and autotopognosia (knowledge of self), the Proverbs Test, and the Ten-point Clock Test. For these patients scores on the Clock Test correlated significantly with semantic abilities, with abstract reasoning capacities, visuospatial perception, and with right and left recognition.

Comparison of the use of screening tools for evaluating cognitive impairment in patients with Parkinson's disease

Background

Screening tests have been used for cognitive deficits in Parkinson's disease (PD).

Objective

This study compared the Montreal Cognitive Assessment (MoCA) test, the Mini-Mental State Examination (MMSE) and the clock drawing test for this purpose.

Methods

A total of 50 patients with PD were selected, 41 (82%) were diagnosed with dementia by the criteria of the Movement Disorder Society. The test Scales for Outcomes in Parkinson's Disease-Cognition (SCOPA-Cog) was used as the gold standard in comparison with the screening tests.

Results

The MoCA test (AUC=0.906) had a sensitivity of 87.80% and specificity of 88.89%. When the MMSE was associated with the clock drawing test (AUC=0.936), it had a specificity of 66.67% and sensitivity of up to 97.56%.

Conclusion

The study suggests that the MoCA test can be a good screening test in PD. However, MMSE associated with the clock drawing test may be more effective than the MoCA test.

Alzheimer's Disease: Prototype of Cognitive Deterioration, Valuable Lessons to Understand Human Cognition

It is important for neurologists to become more familiar with neuropsychological evaluation for Alzheimer disease. The growth of this method in research, as an available, inexpensive, and noninvasive diagnostic approach, which can be administered even by non-specialist-trained examiners, makes this knowledge more necessary than ever. Such knowledge has a basic role in planning national programs in primary health care systems for prevention and early detection of Alzheimer disease. This is more crucial in developing countries, which have higher rates of dementia prevalence along with cardiovascular risk factors, lack of public knowledge about dementia, and limited social support. In addition compared to the neurological hard signs which are tangible and measurable, the concept of cognition seems to be more difficult for the neurologists to evaluate and for the students to understand. Dementia in general and Alzheimer's disease as the prototype of cognitive disorders specifically, play an important role to explore all domains of human cognition through its symptomatology and neuropsychological deficits.

The Clock Drawing Test: Performance differences between the free-drawn and incomplete-copy versions in patients with MCI and dementia

BACKGROUND

The Clock Drawing Test (CDT) is a brief cognitive screening tool for dementia. Several different presentation formats and scoring methods for the CDT are available in the literature.

OBJECTIVE

In this study we aimed to compare performance on the free-drawn and "incomplete-copy" versions of the CDT using the same short scoring method in Mild Cognitive Impairment (MCI) and dementia patients, and healthy elderly participants.

METHODS

90 participants (controlled for age, sex and education) subdivided into control group (n=20), MCI group (n=30) and dementia group (n=40) (Alzheimer's disease - AD=20; Vascular Dementia - VD=20) were recruited for this study. The participants performed the two CDT versions at different times and a blinded neuropsychologist scored the CDTs using the same scoring system.

RESULTS

The scores on the free-drawn version were significantly lower than the incomplete-copy version for all groups. The dementia group had significantly lower scores on the incomplete-copy version of the CDT than the control group. MCI patients did not differ significantly from the dementia or control groups. Performance on the free-drawn copy differed significantly among all groups.

CONCLUSION

The free-drawn CDT version is more cognitively demanding and sensitive for detecting mild/early cognitive impairment. Further evaluation of the diagnostic value (accuracy) of the free-drawn CDT in Brazilian MCI patients is needed.

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.

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

The Clock Drawing Test (CDT) is an inexpensive, fast and easily administered measure of cognitive function, especially in the elderly. This instrument is a popular clinical tool widely used in screening for cognitive disorders and dementia. The CDT can be applied in different ways and scoring procedures also vary.

Objective

The aims of this study were to analyze the performance of elderly on the CDT and evaluate inter-rater reliability of the CDT scored by using a specific algorithm method adapted from Sunderland et al. (1989).

Methods

We analyzed the CDT of 100 cognitively normal elderly aged 60 years or older. The CDT ("free-drawn") and Mini-Mental State Examination (MMSE) were administered to all participants. Six independent examiners scored the CDT of 30 participants to evaluate inter-rater reliability.

Results and Conclusion

A score of 5 on the proposed algorithm ("Numbers in reverse order or concentrated"), equivalent to 5 points on the original Sunderland scale, was the most frequent (53.5%). The CDT specific algorithm method used had high inter-rater reliability (p<0.01), and mean score ranged from 5.06 to 5.96. The high frequency of an overall score of 5 points may suggest the need to create more nuanced evaluation criteria, which are sensitive to differences in levels of impairment in visuoconstructive and executive abilities during aging.

The six-item Clock Drawing Test - reliability and validity in mild Alzheimer's disease

This study presents a reliable, short and practical version of the Clock Drawing Test (CDT) for clinical use and examines its diagnostic accuracy in mild Alzheimer's disease versus elderly nonpatients. Clock drawings from 231 participants were scored independently by four clinical neuropsychologists blind to diagnostic classification. The interrater agreement of individual scoring criteria was analyzed and items with poor or moderate reliability were excluded. The classification accuracy of the resulting scoring system - the six-item CDT - was examined. We explored the effect of further reducing the number of scoring items on classification accuracy and estimated classification accuracy associated with performances deviating from the optimal cutoff score. At a cutoff of 5/6, the six-item CDT had a sensitivity (SN) of 0.65 and a specificity of 0.80. Stepwise removal of up to three items reduced SN slightly. Classification accuracy associated with a score of four or less out of six was very high.

Cognitive impairment in native Chinese with spinocerebellar ataxia type 3

BACKGROUND

Previous studies have shown cognitive impairment in patients with spinocerebellar ataxia type 3 (SCA3). However, there is a lack of data on Chinese patients with SCA3.

METHOD

We investigated 22 native Chinese with SCA3 and 18 controls matched for age, education as well as mental status. Cognitive assessments were carefully carried out to measure verbal fluency, memory, attention, executive function, visuospatial and visuoconstructive functions.

RESULTS

The most common impairments of cognition in native Chinese with SCA3 were disruption of phonemic verbal fluency and frontal executive dysfunction. Deficits in semantic fluency were detected in about 31.8% patients. Impaired visuospatial function and verbal memory were also found in native Chinese with SCA3. The degree of ataxia, CAG repeat length and education were found to correlate with cognitive performance. Multivariate binary logistic regression suggested that an oculomotor disorder and depression are predictors of cognitive impairment.

CONCLUSION

Native Chinese with SCA3 had cognitive impairment of frontal executive function, temporal and parietal functions. An oculomotor disorder might be an index of cognitive dysfunction.

Combining select neuropsychological assessment with blood-based biomarkers to detect mild Alzheimer's disease: a molecular neuropsychology approach

BACKGROUND

Current work has sought to establish a rapid and cost effective means of screening for Alzheimer's disease (AD) with the most recent findings showing utility of integrating blood-based biomarkers with cognitive measures.

OBJECTIVE

The current project sought to create a combined biomarker-cognitive profile to detect mild AD.

METHODS

Data was analyzed from 266 participants (129 AD cases [Early AD n = 93; Very Early AD n = 36]; 137 controls) enrolled in the Texas Alzheimer's Research and Care Consortium (TARCC). Non-fasting serum samples were collected from each participant and assayed via a multi-plex biomarker assay platform using electrochemiluminescence. Logistic Regression was utilized to detect early AD using two serum biomarkers (TNFα and IL7), demographic information (age), and one neuropsychological measure (Clock 4-point) as predictor variable. Disease severity was determined via Clinical Dementia Rating (CDR) scale global scores.

RESULTS

In the total sample (all levels of CDR scores), the combination of biomarkers, cognitive test score, and demographics yielded the obtained sensitivity (SN) of 0.94, specificity (SP) of 0.90, and an overall accuracy of 0.92. When examining early AD cases (i.e.m CDR = 0.5-1), the biomarker-cognitive profile yielded SN of 0.94, SP of 0.85, and an overall accuracy of 0.91. When restricted to very early AD cases (i.e., CDR = 0.5), the biomarker-cognitive profile yielded SN of 0.97 and SP of 0.72, with an overall accuracy of 0.91.

CONCLUSIONS

The combination of demographics, two biomarkers, and one cognitive test created a biomarker-cognitive profile that was highly accurate in detecting the presence of AD, even in the very early stages.

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.

Cognitive screening of older adults: the utility of pentagon drawing

BACKGROUND

Drawing tests have a long history in neuropsychological assessment. A popular geometric figure has been the two intersecting pentagons from the Bender Gestalt test. Reproducing the pentagons is the main visuospatial task on the original Mini-Mental State Examination (MMSE), remaining in use in revised versions of that widely used screening test. Scoring criteria on the MMSE are binary: perfect reproduction of the figure is required, while the Modified MMSE of Teng and Chui (1987) uses a more refined ten-point scoring for the elements of the figure.

METHODS

Here, I report on the use of pentagon drawing from 8,702 older community-dwelling Canadians (59.3% female), with a mean age of 75.5 years (SD = 6.99) and 10.1 years of education (SD = 3.89). Mean scores for the whole sample are reported, as well as for subsamples who underwent a full clinical assessment and were diagnosed as cognitively intact, with dementia, or cognitively impaired, but without dementia. Logistic regression was used to evaluate the utility of pentagon drawing as a diagnostic tool to diagnose cognitive impairment.

RESULTS

Binary scoring was less effective in discriminating groups than the ten-point system and showed weaker properties by other criteria.

CONCLUSIONS

The discussion focuses on the role of simple, non-verbal tasks in the cognitive screening of older adults.

Clock drawing test in elderly individuals with different education levels: correlation with clinical dementia rating

OBJECTIVE

The aim of this study was to describe the performance in Clock Drawing Test (CDT) of the elderly individuals assessed in a geriatric clinic, with at least 1 year of schooling, comparing with other groups with higher education and with Clinical Dementia Rating (CDR) levels. The study also aims to correlate the results of CDT and other used diagnostic tests for dementia by CDR levels, providing additional validity evidence to the CDT.

METHODS

Cross-sectional study with 426 elderly individuals, >60 years old and at least 1 year of education. All participants searched for medical assistance at Geriatric and Gerontology Ambulatory of Jundiaí city, in Brazil. The community-dwelling outpatients previously undergone a detailed clinical examination and neuropsychological evaluation: Cambrigde Cognitive Examination (CAMCOG), Mini-Mental State Examination (MMSE), andCDT. To differentiate data from diagnostic groups based on CDR, it Kruskal-Wallis test was used. Pearson statistics were calculated to compare data from CDT and CDR. The statistical analyses were 2-tailed and were considered significant when P < .05.

RESULTS

Regarding CDT, groups with more years of schooling showed similar means in CDR = 0 and CDR = 0.5 and in CDR = 1 and CDR = 2. Shulman and Sunderland scale were high score in groups with more years of education and above of cutoff points in all CDT score. On the contrary, in Mendez scale we did not observed similar means. Otherwise, in the group with less years of schooling greater means differences in the CDT were observed.

CONCLUSION

The CDT did not show a strong correlation with MMSE and CAMCOG, both important instruments in Brazilian population to investigate dementia. For elderly individuals with high education levels, the CDT did not seem to be a good test to detect cognitive impairment.

Diagnostic accuracy of a new instrument for detecting cognitive dysfunction

BACKGROUND

Effective screening of cognitive disorders is limited by psychometric and practical properties of available instruments. The Brief Cognitive Screen (BCS) was developed to improve sensitivity and overall diagnostic accuracy of case detection for cognitive dysfunction in a quick and convenient format.

METHODS

This validation study compared psychometric properties of the BCS with the Mini mental state examination (MMSE) in 308 patients with suspected or known disorders of cognition. Diagnostic accuracy of the MMSE was determined using the traditional 23/24 clinical cutoff and area under the curve (AUC) from receiver operating characteristics (ROC) analyses. Diagnostic accuracy of BCS summary scores and components was determined by ROC analyses. Comprehensive neuropsychological evaluation served as the criterion standard for determining cognitive dysfunction.

RESULTS

The MMSE sensitivity (34.8%) was inadequate at the 23/24 cutoff. Under ROC analyses, diagnostic accuracy of a BCS summary score was superior (AUC = 0.950) to the MMSE total score (AUC = 0.862) for the total sample. Excluding all patients with a history of cognitive deficit, classification accuracy of the BCS remained high (AUC = 0.936).

CONCLUSIONS

Findings suggest that BCS is an effective, convenient alternative screening instrument for use in clinical populations with suspected cognitive dysfunction.

Suitability of neuropsychological tests in patients with vascular dementia (VaD)

The concept of vascular dementia (VaD) has evolved with the introduction of vascular cognitive impairment (VCI). VaD patients show predominantly frontal cognitive deficits. The executive area is particularly affected, while memory deficits are less frequent in patients with VaD than patients with AD. Several neuropsychological tests are available for the diagnosis and differentiation of dementias, but there are currently no tests developed specifically for VaD. We proposed to evaluate various neuropsychological tests, on the basis of evidence from different studies, in order to clarify the utility of the neuropsychological assessment in vascular dementia.

Population-based distribution and psychometric properties of a short cognitive performance measure in the population-based Heinz Nixdorf Recall Study

BACKGROUND

Providing a valid and sensitive measure of different domains of cognitive performance in epidemiologic studies of early old-age populations presents a methodological challenge, given the broad range of variability in cognitive functioning in this age group.

OBJECTIVES

(1) To provide data on the distribution of cognitive performance scores in a representative sample of an early old-age population, and (2) to assess psychometric properties of a short cognitive performance measure developed within the framework of a cohort study.

DESIGN

Population-based cohort study.

SETTING AND PARTICIPANTS

As part of the second examination of the Heinz Nixdorf Recall Study, 4,145 participants aged 50-80 years underwent a short cognitive performance assessment composed of 5 subtests with a mean duration of 7.31 min. Additionally, a subsample of 656 participants had a detailed neuropsychological and neurological examination.

METHODS

Age- and education-specific cognitive performance scores in the total sample were calculated. Based on data from the subsample, concurrent validity was examined by comparing findings with a clinically validated neuropsychological assessment.

RESULTS

In the total sample, younger and more highly educated participants had higher scores of cognitive performance. In the subsample, a good accuracy [area under the curve (AUC) = 0.81 (0.74-0.87)] of the short cognitive performance assessment compared with results from a clinically established Alzheimer disease assessment scale and diagnosis of mild cognitive impairment [AUC = 0.82 (0.78-0.82)] was observed.

CONCLUSION

This brief, cognitive performance measure, documenting good psychometric properties, can be useful in future epidemiological investigations exploring different domains and overall cognitive functioning in early old-age populations.

Quantitative and qualitative analyses of the clock drawing test in mild cognitive impairment and Alzheimer disease: evaluation of a modified scoring system

The clock drawing test (CDT) has been used as a screening tool for identifying cognitive decline in individuals with Alzheimer disease (AD) and other dementias but has not been extensively evaluated for categorizing individuals with mild cognitive impairment (MCI). This study used both an established quantitative scoring system and a revised scoring method based on qualitative error criteria developed by Rouleau et al to demonstrate the sensitivity of the CDT to MCI. Participants were 66 cognitively healthy older adult, 33 individuals with MCI, and 33 individuals with AD. Sensitivity analyses of the 2 clock drawing methods revealed that the Modified Rouleau scoring method was more sensitive to MCI than the original Rouleau scoring system. Conceptual, graphic, and spatial-planning difficulties were the most commonly committed errors on the CDT across all groups, and conceptual errors along with graphic difficulties were committed more often in the MCI group than the cognitively healthy control group. Participants in the AD group exhibited greater deficits in all error categories and significantly lower total CDT scores compared to both the MCI and older adult controls. Findings observed in this study suggest that qualitative observations of clock drawing errors can help increase sensitivity of the CDT to MCI and that use of a more detailed scoring system is necessary to differentiate individuals with MCI from cognitively healthy older adults.

Application of AD8 questionnaire to screen very mild dementia in Taiwanese

The AD8 questionnaire developed by Washington University in St Louis is a screening tool with 8 questions to reliably differentiate nondemented from demented individuals even at the very mild stage. We recruited 239 participants, including 114 cognitively normal, 73 very mild dementia, and 52 mild dementia to validate its application in Taiwanese. The cut-off value of AD8 was 2 in discriminating cognitively normal from demented individuals with the area under curve (AUC) = 0.961, sensitivity = 97.6%, specificity = 78.1%, positive likelihood ratio (PLR) = 4.5, and negative likelihood ratio (NLR) = 0.03. The cut-off value also was 2 in discriminating nondemented from very mild dementia with the AUC = 0.948, sensitivity = 95.9%, specificity = 78.1%, PLR = 4.4, and NLR = 0.05. The Chinese AD8 is effective in discriminating individuals with dementia, even at its mildest stages from those without dementia with properties identical to the original English version. The cAD8 is a quick dementia screening tool that can be applied across cultures.

New developments in the diagnosis of dementia

BACKGROUND

The terms "dementia" and "Alzheimer's disease" are often wrongly used as if they were synonyms. Dementia is a clinical syndrome whose main element is memory impairment; it is due to Alzheimer's disease in more than 75% of cases. Alzheimer's disease, on the other hand, is a neuropathological entity that is characterized by a protracted preclinical phase followed by the onset of slowly progressive dementia.

METHODS

We here review relevant literature that we retrieved by a selective Medline search (2005-2009), paying special attention to the early diagnosis of Alzheimer's disease, its clinical manifestations, and its relevance in primary care.

RESULTS

The early clinical manifestations of a dementing illness can be detected in primary care through the use of simple screening tests such as the mini mental state examination, clock drawing tests, and DemTect. A diminished concentration of Abeta-peptide and an increase of (phospho-)tau in the cerebrospinal fluid can suggest the presence of Alzheimer's disease even before the onset of dementia: these substances are components of amyloid plaques and neurofibrillary tangles, which are the characteristic neuropathological lesions of Alzheimer's disease. New types of morphological magnetic resonsance imaging (MRI), and automated analysis of the images obtained, can improve the consistency of radiological assessment over the traditional visual method and thus enable more secure diagnosis.

CONCLUSION

The early, preclinical phase of Alzheimer's disease involves what has been termed mild cognitive impairment and may last as long as five years until the onset of dementia. With the aid of the new biomarkers described here, the likelihood of diagnosing Alzheimer's disease correctly in this phase can be raised above 80%. Early detection of Alzheimer's disease before the onset of dementia provides an opportunity to study potential approaches for secondary prevention, which are now an object of intense clinical research.

A quick dementia screening tool for primary care physicians

The accuracy and consuming-time of screening methods are important factors in the early diagnosis of dementia. In this study, we aimed to know whether the eight-item test (including three-item recall, attention and calculation, subtracted from the mini-mental state examination (MMSE), clock drawing test (CDT), and instrumental activities of daily living (IADL) impairment or any combination of the above tests can be used as a quick and effective dementia screening tool. A total of 188 seniors aged over 60 years were enrolled at a geriatric clinic. The result revealed that a cutoff score of 6/7 in an eight-item scale had a sensitivity of 94.9% and a specificity of 59.1% in the detection of dementia. In terms of sensitivity and specificity, the eight-item scale performed better than a score of two in three-item recall (51.3%/87.3%), a score of one in three-item recall (83.3%/53.6%), CDT (39.0%/96.9%), mini-cognitive assessment instrument (Mini-Cog) test (53.7%/95.5%), a score of less than three in attention/calculation test (74.7%/77.3%), impairment of transportation or medication in IADL (67.2%/90.6%), and any impairment in IADL (77.2%/67.9%). In subgroup analysis, a cutoff score of 5/6 were adjusted for the low-education group. We conclude that an eight-item test is a sufficient and simple tool for the screening of early dementia in primary-care clinics focused on older people care.

Performance-based measures of everyday function in mild cognitive impairment

OBJECTIVE

The view that everyday function is preserved in mild cognitive impairment may be problematic. The objectives of this study were to determine the magnitude of impairment in everyday function in patients with mild cognitive impairment and Alzheimer's disease using a novel sensitive performance-based measure (the UCSD Performance-Based Skills Assessment; UPSA), contrast it with use of an informant-based measure (the Alzheimer's Disease Cooperative Study-Activities of Daily Living Inventory; ADCS-ADL), and model the relationship between cognitive measures and the performance-based measure.

METHOD

Fifty cognitively normal elders, 26 patients who met criteria for amnestic mild cognitive impairment, and 22 patients who suffered from mild to moderate Alzheimer's disease were assessed on the UPSA, the ADCS-ADL, and a battery of neurocognitive tests.

RESULTS

Patients with mild cognitive impairment had significant impairments on the UPSA but not on the ADCS-ADL. The magnitude of the effect size between the cognitively healthy and the mild cognitive impairment group for the UPSA was large (d=0.86). A strong and significant relationship was observed between cognitive performances in speed (R(2)=0.37), episodic memory (R(2)=0.10), and semantic processing (R(2)=0.03) and UPSA score using multiple regression models. The psychometric properties of the UPSA were acceptable, as were its sensitivity and specificity in contrasts between cognitively normal elders and patients with mild cognitive impairment and between the latter group and patients with Alzheimer's disease.

CONCLUSIONS

These findings indicate that performance-based measures of function may be a sensitive tool in studies of Alzheimer's disease and mild cognitive impairment and suggest the need for a reconceptualization of the relationship between cognition and function in mild cognitive impairment so that they can be usefully aligned.

Self-administered Gerocognitive Examination (SAGE): a brief cognitive assessment Instrument for mild cognitive impairment (MCI) and early dementia

OBJECTIVES

To develop a self-administered cognitive assessment instrument to facilitate the screening of mild cognitive impairment (MCI) and early dementia and determine its association with gold standard clinical assessments including neuropsychologic evaluation.

METHODS

Adults aged above 59 years with sufficient vision and English literacy were recruited from geriatric and memory disorder clinics, educational talks, independent living facilities, senior centers, and memory screens. After Self-administered Gerocognitive Examination (SAGE) screening, subjects were randomly selected to complete a clinical evaluation, neurologic examination, neuropsychologic battery, functional assessment, and mini-mental state examination (MMSE). Subjects were identified as dementia, MCI, or normal based on standard clinical criteria and neuropsychologic testing.

RESULTS

Two hundred fifty-four participants took the SAGE screen and 63 subjects completed the extensive evaluation (21 normal, 21 MCI, and 21 dementia subjects). Spearman rank correlation between SAGE and neuropsychologic battery was 0.84 (0.76 for MMSE). SAGE receiver operating characteristics on the basis of clinical diagnosis showed 95% specificity (90% for MMSE) and 79% sensitivity (71% for MMSE) in detecting those with cognitive impairment from normal subjects.

CONCLUSIONS

This study suggests that SAGE is a reliable instrument for detecting cognitive impairment and compares favorably with the MMSE. The self-administered feature may promote cognitive testing by busy clinicians prompting earlier diagnosis and treatment.

Diagnostic accuracy of a new instrument for detecting cognitive dysfunction in an emergent psychiatric population: the Brief Cognitive Screen

OBJECTIVES

In certain clinical contexts, the sensitivity of the Mini-Mental State Examination (MMSE) is limited. The authors developed a new cognitive screening instrument, the Brief Cognitive Screen (BCS), with the aim of improving diagnostic accuracy for cognitive dysfunction in the psychiatric emergency department (ED) in a quick and convenient format.

METHODS

The BCS, consisting of the Oral Trail Making Test (OTMT), animal fluency, the Clock Drawing Test (CDT), and the MMSE, was administered to 32 patients presenting with emergent psychiatric conditions. Comprehensive neuropsychological evaluation served as the criterion standard for determining cognitive dysfunction. Diagnostic accuracy of the MMSE was determined using the traditional clinical cutoff and receiver operating characteristic (ROC) curve analyses. Diagnostic accuracy of individual BCS components and BCS Summary Scores was determined by ROC analyses.

RESULTS

At the traditional clinical cutoff, MMSE sensitivity (46.4%) and total diagnostic accuracy (53.1%) were inadequate. Under ROC analyses, the diagnostic accuracy of the full BCS Summary Score (area under the curve [AUC]=0.857) was comparable to the MMSE (AUC=0.828). However, a reduced BCS Summary Score consisting of OTMT Part B (OTMT-B), animal fluency, and the CDT yielded classification accuracy (AUC=0.946) that was superior to the MMSE.

CONCLUSIONS

Preliminary findings suggest the BCS is an effective, convenient alternative cognitive screening instrument for use in emergent psychiatric populations.

The accuracy of the Clock Drawing Test compared to that of standard screening tests for Alzheimer's disease: results from a study of Brazilian elderly with heterogeneous educational backgrounds

BACKGROUND

Although the Clock Drawing Test (CDT) is the second most used test in the world for the screening of dementia, there is still debate over its sensitivity, specificity, application and interpretation in dementia diagnosis. This study has three main aims: to evaluate the sensitivity and specificity of the CDT in a sample composed of older adults with Alzheimer's disease (AD) and normal controls; to compare CDT accuracy to the that of the Mini-mental State Examination (MMSE) and the Cambridge Cognitive Examination (CAMCOG); and to test whether the association of the MMSE with the CDT leads to higher or comparable accuracy as that reported for the CAMCOG.

METHODS

Cross-sectional assessment was carried out for 121 AD and 99 elderly controls with heterogeneous educational levels from a geriatric outpatient clinic who completed the Cambridge Examination for Mental Disorder of the Elderly (CAMDEX). The CDT was evaluated according to the Shulman, Mendez and Sunderland scales.

RESULTS

The CDT showed high sensitivity and specificity. There were significant correlations between the CDT and the MMSE (0.700-0.730; p < 0.001) and between the CDT and the CAMCOG (0.753-0.779; p < 0.001). The combination of the CDT with the MMSE improved sensitivity and specificity (SE = 89.2-90%; SP = 71.7-79.8%). Subgroup analysis indicated that for elderly people with lower education, sensitivity and specificity were both adequate and high.

CONCLUSIONS

The CDT is a robust screening test when compared with the MMSE or the CAMCOG, independent of the scale used for its interpretation. The combination with the MMSE improves its performance significantly, becoming equivalent to the CAMCOG.

The Clock Drawing Test--Modified and Integrated Approach (CDT-MIA) as an instrument for detecting mild cognitive impairment in a specialized outpatient setting

This study examined the accuracy of the Clock Drawing Test--Modified and Integrated Approach (CDT-MIA) alone and combined with the Mini-Mental State Examination (MMSE) to detect Mild Cognitive Impairment (MCI) in patients with suspected MCI. For comparison, the accuracy of the Cambridge Cognitive Examination-Revised (CAMCOG-R) was tested. A total of 65 elderly outpatients with suspected MCI underwent a comprehensive evaluation. Following assessment, the entire sample was classified into: dementia (mild)--24 participants, MCI--22 participants, no cognitive impairment (NCI)--19 participants. CDT-MIA and the MMSE alone failed to appropriately discriminate demented from nondemented (MCI and NCI) and MCI from NCI. The best acceptable diagnostic accuracy to discriminate between demented and nondemented was obtained with CDT-MIA/MMSE combined and with CAMCOG-R. CDT-MIA/MMSE combined failed to appropriately discriminate MCI from NCI. The best diagnostic accuracy in this regard was obtained with CAMCOG-R.

The minute hand phenomenon in the Clock Test of patients with early Alzheimer disease

Common scoring systems for the Clock Test do not sufficiently emphasize the correct time representation by the clock hands. We compared Clock Drawing, Clock Setting, and Clock Reading in healthy control persons, patients with mild cognitive impairment, early Alzheimer disease and progressed Alzheimer disease particularly analyzing clock time representation. We found that healthy control persons and participants with mild cognitive impairment did not show any impairment in Clock Test performance. Patients with early Alzheimer disease could be discriminated from healthy control persons and participants with mild cognitive impairment solely by misplacement of the minute hand in Clock Drawing and Clock Setting. The progressed Alzheimer disease group showed significantly more impairments in all Clock Test variants. It is assumed that early stage Alzheimer disease patient deficits in Clock Tests are mainly determined by a reduced access to semantic memory about the appearance and functionality of a clock.

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

The Clock Drawing Test (CDT) is a simple neuropsychometric instrument that can be easily applied to assess several cognitive functions. Over the past 20 years, the CDT has aroused considerable interest in its role for the early screening of cognitive impairment, especially in dementia. Although the CDT is considered an accurate test for dementia screening, recent studies including comparisons with structured batteries such as the CAMCOG have shown mixed results.

Objectives

To investigate the importance of the CDT compared to other commonly used tests, in the diagnosis of dementia in the elderly; (2) to evaluate the reliability and correlation between available CDT scoring scales from recent studies.

Methods

A systematic search in the literature was conducted in September 2008 for studies comparing CDT scoring systems and comparing the CDT with neuropsychiatric batteries.

Results

Twelve studies were selected for analyses. Seven of these studies compared CDT scoring scales while five compared the CDT against the CAMCOG and the MMSE. Eight studies found good correlation and reliability between the scales and the other tests.

Conclusion

Despite the mixed results in these studies, the CDT appears to be a good screening test for dementia.

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

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