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Meagher D, Williams OA, O'Connell H, Leonard M, Cullen W, Dunne CP, Mulligan O, Adamis D. A systematic review and meta-analysis of the accuracy of the clock drawing test (CDT) in the identification of delirium in older hospitalised patients. Aging Ment Health 2021; 25:879-888. [PMID: 32091236 DOI: 10.1080/13607863.2020.1727849] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective: Delirium is a common neurocognitive syndrome among hospitalised older adults. The clock drawing test (CDT) is a relatively simple bedside test of cognitive function. This systematic review and meta-analysis examine the accuracy of the CDT in identifying delirium in hospitalised older adults.Methods: PRISMA guidelines were used to report the identified studies. Pubmed, SCOPUS, and Ovid and EBSCO platforms (including MEDLINE ®, PsycINFO, PsycEXTRA, EMCARE, CINAHL and EMBASE databases) were searched. Studies were assessed for methodological quality using the Downs and Black Tool. Data were extracted regarding the number of delirious/not delirious, number with normal and abnormal CDT, age, and MMSE scores, and information regarding CDT scoring, criteria for diagnosis of delirium and setting of the study. Analysis was carried out with the "Mada" and "Metatron" packages of R software.Results: Fifteen studies were examined. The number of participants was 2199, of whom 597 (27.15%) were diagnosed with delirium. The overall sensitivity of CDT in the absence of any formal cognitive test was 0.76 (0.58-0.87) with specificity of 0.70 (0.51-0.83). When the MMSE was taken into account, the specificity and sensitivity reduced to 0.51. Diagnostic criteria for delirium, scoring method of CDT, age of participants and setting significantly (p < 0.05) affect the sensitivity and specificity of the CDT.Conclusion: Although, the CDT is generally considered to be a simple and easy to administer screening tool for cognitive impairment in older hospitalised adults, when a more formal cognitive test is used its sensitivity and specificity to detect delirium is low.
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Affiliation(s)
- David Meagher
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Olugbenga Alaba Williams
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Henry O'Connell
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of General Practice, School of Medicine, University College Dublin, Dublin, Ireland
| | - Maeve Leonard
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of Psychiatry, University Hospital Limerick, Limerick, Ireland
| | - Walter Cullen
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of General Practice, School of Medicine, University College Dublin, Dublin, Ireland
| | - Colum P Dunne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | - Dimitrios Adamis
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Cognitive Impairment Research Group, Centre for Interventions in Infection, Inflammation & Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Sligo Mental Health Services, Sligo, Ireland
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Adamis D, Meagher D, O'Neill D, McCarthy G. The utility of the clock drawing test in detection of delirium in elderly hospitalised patients. Aging Ment Health 2016; 20:981-6. [PMID: 26032937 DOI: 10.1080/13607863.2015.1050996] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Delirium is common neuropsychiatric condition among elderly inpatients. The clock drawing test (CDT) has been used widely as bedside screening tool in assessing cognitive impairment in elderly people. Previous studies which evaluate its usefulness in delirium reported conflicting results. The objective of this study was to evaluate the utility of CDT to detect delirium in elderly medical patients. METHOD Prospective, observational, longitudinal study. All acute medical admissions 70 years of age and above were approached within 72 hours of admission for recruitment. Patients eligible for inclusion were assessed four times, twice weekly during admission. Assessment included Confusion Assessment Method (CAM), Delirium Rating Scale (DRS-98R), Montreal Cognitive Assessment (MoCA), Acute Physiology and Chronic Health Evaluation II (APACHE) II, and CDT. Data was analysed using a linear mixed effect model. RESULTS Three hundred and twenty-three assessments with the CDT were performed on 200 subjects (50% male, mean age 81.13; standard deviation: 6.45). The overall rate of delirium (CAM+) during hospitalisation was 23%. There was a significant negative correlation between the CDT and DRS-R98 scores (Pearson correlation r = -0.618, p < 0.001), CDT and CAM (Spearman's rho = -0.402, p < 0.001) and CDT and total MoCA score (Pearson's r = 0.767, p < 0.001). However, when the data were analysed longitudinally controlling for all the factors, we found that cognitive function and age were significant factors associated with CDT scores (p < .0001): neither the presence nor the severity of delirium had an additional significant effect on the CDT. CONCLUSION CDT score reflects cognitive impairment, independently of the presence or severity of delirium. The CDT is not a suitable test for delirium in hospitalised elderly patients.
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Affiliation(s)
- Dimitrios Adamis
- a Sligo Mental Health Services , Sligo , Ireland.,b Research and Academic Institute of Athens , Athens , Greece
| | - David Meagher
- c Cognitive Impairment Research Group (CIRG) , Graduate-Entry Medical School University of Limerick , Limerick , Ireland
| | | | - Geraldine McCarthy
- a Sligo Mental Health Services , Sligo , Ireland.,d Sligo Medical Academy , NUI Galway and Sligo Mental Health Services , Sligo , Ireland
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Vadalà M, Vallelunga A, Palmieri L, Palmieri B, Morales-Medina JC, Iannitti T. Mechanisms and therapeutic applications of electromagnetic therapy in Parkinson's disease. BEHAVIORAL AND BRAIN FUNCTIONS : BBF 2015; 11:26. [PMID: 26347217 PMCID: PMC4562205 DOI: 10.1186/s12993-015-0070-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 07/22/2015] [Indexed: 12/04/2022]
Abstract
Electromagnetic therapy is a non-invasive and safe approach for the management of several pathological conditions including neurodegenerative diseases. Parkinson's disease is a neurodegenerative pathology caused by abnormal degeneration of dopaminergic neurons in the ventral tegmental area and substantia nigra pars compacta in the midbrain resulting in damage to the basal ganglia. Electromagnetic therapy has been extensively used in the clinical setting in the form of transcranial magnetic stimulation, repetitive transcranial magnetic stimulation, high-frequency transcranial magnetic stimulation and pulsed electromagnetic field therapy which can also be used in the domestic setting. In this review, we discuss the mechanisms and therapeutic applications of electromagnetic therapy to alleviate motor and non-motor deficits that characterize Parkinson's disease.
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Affiliation(s)
- Maria Vadalà
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy.
| | - Annamaria Vallelunga
- Department of Medicine and Surgery, Centre for Neurodegenerative Diseases (CEMAND), University of Salerno, Salerno, Italy.
| | - Lucia Palmieri
- Department of Nephrology, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy.
| | - Beniamino Palmieri
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy.
| | - Julio Cesar Morales-Medina
- Centro de Investigación en Reproducción Animal, CINVESTAV-Universidad Autónoma de Tlaxcala, Tlaxcala, Mexico.
| | - Tommaso Iannitti
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK.
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Saur R, Maier C, Milian M, Riedel E, Berg D, Liepelt-Scarfone I, Leyhe T. Clock test deficits related to the global cognitive state in Alzheimer's and Parkinson's disease. Dement Geriatr Cogn Disord 2012; 33:59-72. [PMID: 22415211 DOI: 10.1159/000336598] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/23/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Clock drawing (CD) seems to be impaired quite early in the process of cognitive decline in Parkinson's disease (PD). METHODS We assessed performance on the CD test (CDT), clock setting test (CST) and clock reading test (CRT) in 32 elderly healthy controls, 41 patients with PD, 23 patients with amnestic mild cognitive impairment (aMCI) and 40 patients with Alzheimer's dementia (AD). Our focus was on comparing the performance of PD and aMCI/AD patients in relation to their global cognitive states (operationalized by the Mini Mental Status Examination). We also analyzed qualitative differences in errors of drawing, setting and reading clocks. RESULTS We found that performance in CDT, but not in the CST or CRT, was impaired earlier in PD than in aMCI/AD. Incorrect placement of the minute hand was the most prominent error in both patient groups. We found no specific influence of visuospatial dysfunction in PD on clock drawing. CONCLUSION Our findings suggest that executive function related to retrieval of semantic memory about the minute hand is compromised early in PD.
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Affiliation(s)
- Ralf Saur
- Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
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Stella F, Gobbi LTB, Gobbi S, Oliani MM, Tanaka K, Pieruccini-Faria F. Early impairment of cognitive functions in Parkinson's disease. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:406-10. [PMID: 17665005 DOI: 10.1590/s0004-282x2007000300008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Accepted: 02/14/2007] [Indexed: 11/22/2022]
Abstract
BACKGROUND: Impairment in non-motor functions such as disturbances of some executive functions are also common events in Parkinson's disease patients. OBJECTIVE: To verify the performance of Parkinson's disease patients in activities requiring visuoconstructive and visuospatial skills. METHOD: Thirty elderly patients with mild or moderate stages of Parkinson's disease were studied. The assessment of the clinical condition was based on the unified Parkinson's disease rating scale (56.28; SD=33.48), Hoehn and Yahr (2.2; SD=0.83), Schwab and England (78.93%), clock drawing test (7.36; SD=2.51), and mini-mental state examination (26.48; SD=10.11). Pearson's correlation and stepwise multiple regression were used for statistical analyses. RESULTS: The patients presented deterioration in visuospatial and visuoconstructive skills. CONCLUSION: The clock drawing test proved to be a useful predictive tool for identifying early cognitive impairment in thesbe individuals.
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Affiliation(s)
- Florindo Stella
- Neuropsychiatry and Mental Health for Elderly, State University of Campinas, Campinas, SP, Brazil.
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Barak Y, Lavie M, Achiron A. Screening for early cognitive impairment in multiple sclerosis patients using the clock drawing test. J Clin Neurosci 2002; 9:629-32. [PMID: 12604271 DOI: 10.1054/jocn.2002.1110] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The clock drawing test (CDT) is a complex task assessing integrative functions, abstract thinking and visuospatial organization. In the present study we evaluated the CDT as a possible screening instrument for early cognitive impairment in multiple sclerosis (MS) patients. In total, 107 MS patients completed the CDT as well as a battery assessing five cognitive domains. There were 73 female and 34 male participants (mean age 45.4+/-11.6 years, range 19-69). The majority (76/107) were diagnosed with a relapsing-remitting disease course. Mean expanded disability status scale (EDSS) score was 4.3+/-2.4 (range 0-8). The CDT was scored on a 1-6 point scale with "1" being a perfect score and "6" reflecting severe disorganization. Mean CDT score was 2.6+/-1.4. In 53% of patients the CDT was normal while in 11.2% dementia was apparent. The CDT score did not correlate with the total EDSS. Significant correlations were obtained with the mental functional system score of the EDSS (r = 0.78; p = 0.0001), visual learning and recall, sustained attention and concentration. Our findings demonstrate the sensitivity of the CDT to several cognitive domains. The absence of correlation with total EDSS score coupled with significant correlation with the mental functional system suggests that the CDT may be useful for screening MS patients.
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Affiliation(s)
- Yoram Barak
- The Doly Steindling Multiple Sclerosis Center, Sheba Medical Center, Tel-Hashomer, Israel.
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Sandyk R. Reversal of cognitive impairment in an elderly parkinsonian patient by transcranial application of picotesla electromagnetic fields. Int J Neurosci 1997; 91:57-68. [PMID: 9394215 DOI: 10.3109/00207459708986365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A 74 year old retired building inspector with a 15 year history of Parkinson's disease (PD) presented with severe resting tremor in the right hand, generalized bradykinesia, difficulties with the initiation of gait with freezing, mental depression and generalized cognitive impairment despite being fully medicated. Testing of constructional abilities employing various drawing tasks demonstrated drawing impairment compatible with severe left hemispheric dysfunction. After receiving two successive transcranial applications, each of 20 minutes duration, with AC pulsed electromagnetic fields (EMFs) of 7.5 picotesla flux density and frequencies of 5Hz and 7Hz respectively, his tremor remitted and there was dramatic improvement in his drawing performance. Additional striking improvements in his drawing performance occurred over the following two days after he continued to receive daily treatments with EMFs. The patient's drawings were subjected to a Reliability Test in which 10 raters reported 100% correct assessment of pre- and post drawings with all possible comparisons (mean 2 = 5.0; p < .05). This case demonstrates in PD rapid reversal of drawing impairment related to left hemispheric dysfunction by brief transcranial applications of AC pulsed picotesla flux density EMFs and suggests that cognitive deficits associated with Parkinsonism, which usually are progressive and unaffected by dopamine replacement therapy, may be partly reversed by administration of these EMFs. Treatment with picotesla EMFs reflects a "cutting edge" approach to the management of cognitive impairment in Parkinsonism.
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Affiliation(s)
- R Sandyk
- Department of Neuroscience, Touro College, Dix Hills, NY 11746, USA
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