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

Analysis of the Clock-Reading Ability in Patients with Cognitive Impairment: Comparison of Analog Clocks and Digital Clocks

Background: Time disorientation is one of the main symptoms observed in patients with dementia; however, their clock-reading ability has not been fully reported. Objective: This study aimed to investigate the clock-reading ability of both digital and analog clocks in patients with dementia. We newly devised the clock-reading test (CRT) and the number-reading test (NRT) to assess cognitive factors that may affect clock-reading ability. Furthermore, the discriminating power of the CRT was calculated. Methods: 104 participants were categorized based on their Mini-Mental State Examination (MMSE) scores as follows: subjective cognitive decline ∼ mild cognitive impairment (SCD∼MCI, N = 43), early Alzheimer’s disease (AD) (N = 26), and middle-to-late AD (N = 35). Their cognitive abilities were evaluated using the clock-drawing test (CDT), CRT, and NRT. Results: Cognitive decline leads to impairment of clock-reading ability which is more pronounced in the analog clocks than digital ones. This deficit in clock-reading is attributed to a loss of semantic memory regarding clocks at all stages. Additionally, visuospatial dysfunction and reduced ability of number recognition may lead to deficit in clock-reading in the advanced stage of AD. The discriminating power of the CRT (analog) (AUC = 0.853) was high enough to detect cognitive decline. Conclusion: Digital clocks are more readable by patients with dementia. Since reading clocks is closely associated with daily life, the CRT has proved to be a useful tool. A decline of analog clock-reading may be an early detector for the onset of dementia in elderly patients.

Clock-drawing test: Normative data of three quantitative scoring methods for Chinese-speaking adults in Shijiazhuang City and clinical utility in patients with acute ischemic stroke

OBJECTIVE

The clock-drawing test (CDT) is a widely used screening tool for detecting cognitive decline. However, normative data for Chinese individuals are scarce. Our study aimed to provide standardized values for the three quantitative CDT scoring methods that were tailored for Chinese-speaking adults in Shijiazhuang City and explore the discriminant validity of the CDT scores in patients with acute ischemic stroke.

METHODS

We conducted the CDT among 418 healthy individuals aged between 35 and 84 years. The CDT was administered and scored by five raters using the method derived from the Montreal Cognitive Assessment (MoCA), Rouleau's, and Babins' scoring systems. The influence of age, education, and sex on the performance in the CDT was analyzed. Furthermore, 336 patients with acute ischemic stroke were enrolled to explore the discriminant validity of CDT scores.

RESULTS

In all three scoring systems, CDT scores were significantly correlated with age and years of education but not with sex. Normative data stratified for age and years of education were established. Interrater and intersystem reliability were high in our study. CDT total scores and subscores showed significant differences between stroke patients and healthy individuals.

CONCLUSIONS

Our study provides CDT normative data using three quantitative scoring methods for Chinese-speaking adults in Shijiazhuang City. Age and education level were the key factors that affected the CDT scores. CDT total scores and subscores provided good discriminant validity for patients with acute ischemic stroke.

Effort Testing in Dementia Assessment: A Systematic Review

Objective

Interpretation of neuropsychological test data is only valid when appropriate effort has been exerted. Research, however, suggests that neuropsychologists do not always formally test for effort and that this may especially be the case in the context of dementia assessment. This review systematically examined the literature that has investigated the use of both purpose-built and embedded effort-sensitive indices in dementia, mild cognitive impairment (MCI), and healthy control samples. The aim was to determine which tests of effort are most sensitive to suboptimal effort and least sensitive to the type of cognitive impairment seen in dementia.

Methods

A systematic search of databases was conducted to October 2017. There was no start date.

Results

Twenty-five studies were included for review. The studies were divided into two categories according to methodology. One category of studies (n = 5) was reviewed using a tailored methodological quality rating checklist whilst the remaining studies (n = 20) were reviewed using the Crowe Critical Appraisal Tool (CCAT).

Conclusions

The results of this review suggest that PVTs which take a hierarchical approach to effort testing such as the WMT, MSVT, and NV-MSVT are preferable for use with older adults who are under investigation for possible dementia. These tests go above and beyond the traditional pass/fail approach of more traditional tests of effort because they allow the examiner to analyze the examinee's profile of scores. The methodological limitations and challenges involved in this field of research are discussed.

The clock-drawing test: normative data in adult and elderly Israeli Arabs

AIM

Despite the widespread use of the clock-drawing test (CDT), normative data and information regarding the influence of sociodemographic factors on test performance by adult and elderly Israeli Arabs are lacking. The current study aimed to establish normative data for this population group by exploring the impact of sociodemographic factors such as age, education, and gender on CDT performance. In addition, this study examined the association between CDT performance and Mini-Mental State Examination (MMSE) scores.

METHODS

The sample consisted of 295 community-dwelling healthy adult and elderly Israeli Arabs, aged 20-86 years, with a MMSE score ≥24. The MMSE and the CDT were administered to participants.

RESULTS

Statistical analyses revealed that age had a negative effect on CDT performance, which was most pronounced in the 60-86 age group, but education and occupation (academic vs non-academic) had a positive effect. Gender and place of residence (urban vs rural) had no effect. CDT performance predicted the MMSE score.

CONCLUSIONS

The present study provides preliminary normative data on adult and elderly Israeli Arabs. The CDT appears to be applicable to Israeli Arabs, while the normative data might help interpret cognitive function results in this population.

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

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

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.

Outcome measures for Parkinson's disease dementia: a systematic review

BACKGROUND

Parkinson's disease dementia (PDD) is a major cause of morbidity and mortality in Parkinson's disease (PD), which severely affects patient functioning and quality of life and increases the risk for nursing home admission. Unfortunately, current treatment options for PDD are limited and have only marginal therapeutic effects. As novel treatments are developed, there will be a need to assess their efficacy in well-designed randomized controlled trials. However, there is no consensus on the optimal outcome measures for use in PDD clinical trials.

METHODS

A systematic review of PDD clinical trials and empiric studies of outcome measures used in PDD was performed. Outcome measures were divided into five categories: 1) cognitive; 2) behavioral and mood; 3) activities of daily living and quality of life; 4) global; and 5) caregiver burden.

FINDINGS

A total of 20 PDD pharmacologic clinical trials were identified. These trials incorporated a broad array of outcome measures, which were used inconsistently across trials. We summarize the psychometric properties and other relevant data on outcome measures used, including their diagnostic utility, inter-rater reliability, test-retest reliability, responsiveness, clinically meaningful change, and availability of alternate forms.

CONCLUSIONS

We have identified the best-evidenced PDD outcome measures in each domain. Further research is needed to assess the validity, reliability, and clinically meaningful change of these measures in PDD to inform the design of future clinical trials and enhance the ability of clinicians, researchers and policy-makers to interpret study results. In addition, the development of outcome measures specific to PDD may be warranted.

Poder preditivo do MoCa na avaliação neuropsicológica de pacientes com diagnóstico de demência

O estudo teve como objetivo correlacionar testes neuropsicométricos em idosos com mais de quatro anos de escolaridade e avaliar a acurácia do MoCA no diagnóstico da doença de Alzheimer (DA) e comprometimento cognitivo leve (CCL). Foram avaliados 136 idosos atendidos no Instituto de Geriatria e Gerontologia, no período de abril de 2010 a dezembro de 2012. Os instrumentos utilizados foram o Miniexame do Estado Mental (MEEM), Cambridge Cognitive Examination (CAMCOG), teste do Desenho do Relógio (TDR), teste de Fluência Verbal, Escala de Depressão Geriátrica e Questionário de Atividades Funcionais de Pfeffer (QAFP), além do teste Montreal Cognitive Assessment (MoCA). Foi utilizada a análise de curva ROC para se estabelecer pontos de corte, e o coeficiente de correlação de Pearson, a fim de comparar o MoCA com os outros testes. Os resultados mostraram que o teste MoCA foi o melhor para diferenciar doença de Alzheimer dos casos de CCL. A sensibilidade e a especificidade encontradas foram, respectivamente, 82,2% e 92,3%. A análise do teste de correlação evidenciou que o MoCA se correlacionou fortemente com outros testes já validados e de ampla aplicação no Brasil. Pode-se concluir que o MoCA mostrou ser o teste com maior valor preditivo para diferenciar DA de CCL e também diferenciar CCL dos controles normais. Além disso, o MoCA se correlacionou de maneira significativa com a variável idade e os testes MEEM, CAMCOG, TDR, de Fluência Verbal e QAFP, instrumentos já validados e amplamente utilizados no Brasil.

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.

Longitudinal changes in clock drawing test (CDT) performance before and after cognitive decline

Background

Many scoring systems exist for clock drawing task variants. However, none of them are reliable in evaluating longitudinal changes of cognitive function. The purpose of this study is to create a simple yet optimal scoring procedure to evaluate cognitive decline using a clinic-based sample.

Methods

Clock-drawings from 121 participants (76 individuals with no dementia and later did not develop dementia after a mean 41.2-month follow-up, 45 individuals with no dementia became demented after a mean 42.3-month follow-up) were analyzed using t-test to determine a new and simplified CDT scoring system. The new scoring method was then compared with other commonly used systems.

Results

In the converters, there were only 7 items that are significantly different between the initial visits and the second visits. We propose a new scoring system that includes the seven critical items: numbers are equally spaced (12–3–6–9) (p = 0.031), the other eight numbers are marked (p = 0.022), numbers are clockwise (p = 0.002), all numbers are correct (p = 0.030), distance between numbers is constant (p = 0.016), clock has two hands (p = 0.000), arrows are drawn (p = 0.003). Compared with other traditionally used scoring methods, this based change clock drawing test (BCCDT) has one of the most balanced sensitivities/specificities with a clinic-based sample.

Conclusions

The new CDT scoring system provides further evidence in support of a simple and reliable clock-drawing scoring system in follow-up studies to evaluate cognitive decline, which can be used in assessing the efficacy of medicine.

Comparison of the diagnostic accuracy of neuropsychological tests in differentiating Alzheimer's disease from mild cognitive impairment: can the montreal cognitive assessment be better than the cambridge cognitive examination?

OBJECTIVE

Considering the lack of studies on measures that increase the diagnostic distinction between Alzheimer's disease (AD) and mild cognitive impairment (MCI) and on the role of the Cambridge Cognitive Examination (CAMCOG) in this, our study aims to compare the utility of the CAMCOG, Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) in helping to differentiate AD from MCI in elderly people with >4 years of schooling.

METHOD

A total of 136 elderly subjects - 39 normal controls as well as 52 AD patients and 45 MCI patients treated at the Institute of Geriatrics and Gerontology, Porto Alegre, Brazil - were assessed using the MMSE, CAMCOG, clock drawing test (CDT), verbal fluency test (VF), Geriatric Depression Scale and Pfeffer Functional Activities Questionnaire.

RESULTS

The results obtained by means of a receiver operating characteristic curve showed that the MoCA is a better screening test for differentiating elderly subjects with AD from those with MCI than the CAMCOG and MMSE as well as other tests such as the CDT and VF.

CONCLUSION

The MoCA, more than the CAMCOG and the other tests, was shown to be able to differentiate AD from MCI, although, as Roalf et al. [Alzheimers Dement 2013;9:529-537] pointed out, further studies might lead to measures that will improve this differentiation.

Applications of technology in neuropsychological assessment

Most neuropsychological assessments include at least one measure that is administered, scored, or interpreted by computers or other technologies. Despite supportive findings for these technology-based assessments, there is resistance in the field of neuropsychology to adopt additional measures that incorporate technology components. This literature review addresses the research findings of technology-based neuropsychological assessments, including computer- and virtual reality-based measures of cognitive and functional abilities. We evaluate the strengths and limitations of each approach, and examine the utility of technology-based assessments to obtain supplemental cognitive and behavioral information that may be otherwise undetected by traditional paper-and-pencil measures. We argue that the potential of technology use in neuropsychological assessment has not yet been realized, and continued adoption of new technologies could result in more comprehensive assessment of cognitive dysfunction and in turn, better informed diagnosis and treatments. Recommendations for future research are also provided.

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.

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.

Using the Folstein Mini Mental State Exam (MMSE) to explore methodological issues in cognitive aging research

Cognitive scales are used frequently in geriatric research and practice. These instruments are constructed with underlying assumptions that are a part of their validation process. A common measurement scale used in older adults is the Folstein Mini Mental State Exam (MMSE). The MMSE was designed to screen for cognitive impairment and is used often in geriatric research. This paper has three aims. Aim one was to explore four potential threats to validity in the use of the MMSE: (1) administering the exam without meeting the underlying assumptions, (2) not reporting that the underlying assumptions were assessed prior to test administration, (3) use of variable and inconsistent cut-off scores for the determination of presence of cognitive impairment, and (4) failure to adjust the scores based on the demographic characteristics of the tested subject. Aim two was to conduct a literature search to determine if the assumptions of (1) education level assessment, (2) sensory assessment, and (3) language fluency were being met and clearly reported in published research using the MMSE. Aim three was to provide recommendations to minimalize threats to validity in research studies that use cognitive scales, such as the MMSE. We found inconsistencies in published work in reporting whether or not subjects meet the assumptions that underlie a reliable and valid MMSE score. These inconsistencies can pose threats to the reliability of exam results. Fourteen of the 50 studies reviewed reported inclusion of all three of these assumptions. Inconsistencies in reporting the inclusion of the underlying assumptions for a reliable score could mean that subjects were not appropriate to be tested by use of the MMSE or that an appropriate test administration of the MMSE was not clearly reported. Thus, the research literature could have threats to both validity and reliability based on misuse of or improper reported use of the MMSE. Six recommendations are provided to minimalize these threats in future research.

Normative performance on the executive clock drawing task in a multi-ethnic bilingual cohort: a project FRONTIER study

BACKGROUND

The executive clock drawing task (CLOX) test is a neuropsychological measure intended to aid in the assessment and detection of dementia in older populations. Few studies have provided normative data for this measure, with even less research available regarding the impact of sociodemographic factors on test scores. This study presents normative data for the CLOX in a sample of English and Spanish-speaking Hispanic and non-Hispanic Whites.

METHODS

The total sample included 445 cognitively healthy older adults seen as part of an ongoing study of rural cognitive aging, project FRONTIER. Unlike previous studies, criteria for "normality" (i.e., unimpaired) for CLOX1 and CLOX2 were based not merely on global impairment, but also on domain-specific impairment of executive functioning on the Executive Interview 25-item Examination and/or Trail Making Test B, or visuospatial/constructional impairment on the Line Orientation and Figure Copy subtests of the Repeatable Battery for the Assessment of Neuropsychological Status, respectively.

RESULTS

Hierarchical regression analyses revealed that CLOX1 scores require adjustment by Age across ethnicities, whereas Education and Gender are necessary stratification markers for CLOX1 performance only in non-Hispanic Whites. None of the demographic variables were valid predictors of CLOX2 performance, negating the need for such adjustments.

CONCLUSION

In addition to being the first study to provide separate normative data for CLOX performance in Hispanic and non-Hispanic White samples, the current study offers a novel approach to defining "normal" by cognitive domain. We also highlight the need to directly examine the impact of sociodemographic factors before applying normative corrections based on factors that have negligible impact on test scores.

Using the Folstein Mini Mental State Exam (MMSE) to explore methodological issues in cognitive aging research

Cognitive scales are used frequently in geriatric research and practice. These instruments are constructed with underlying assumptions that are a part of their validation process. A common measurement scale used in older adults is the Folstein Mini Mental State Exam (MMSE). The MMSE was designed to screen for cognitive impairment and is used often in geriatric research. This paper has three aims. Aim one was to explore four potential threats to validity in the use of the MMSE: (1) administering the exam without meeting the underlying assumptions, (2) not reporting that the underlying assumptions were assessed prior to test administration, (3) use of variable and inconsistent cut-off scores for the determination of presence of cognitive impairment, and (4) failure to adjust the scores based on the demographic characteristics of the tested subject. Aim two was to conduct a literature search to determine if the assumptions of (1) education level assessment, (2) sensory assessment, and (3) language fluency were being met and clearly reported in published research using the MMSE. Aim three was to provide recommendations to minimalize threats to validity in research studies that use cognitive scales, such as the MMSE. We found inconsistencies in published work in reporting whether or not subjects meet the assumptions that underlie a reliable and valid MMSE score. These inconsistencies can pose threats to the reliability of exam results. Fourteen of the 50 studies reviewed reported inclusion of all three of these assumptions. Inconsistencies in reporting the inclusion of the underlying assumptions for a reliable score could mean that subjects were not appropriate to be tested by use of the MMSE or that an appropriate test administration of the MMSE was not clearly reported. Thus, the research literature could have threats to both validity and reliability based on misuse of or improper reported use of the MMSE. Six recommendations are provided to minimalize these threats in future research.

Vascular dementia: Cognitive, functional and behavioral assessment. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Part II

Vascular dementia (VaD) is the most prevalent form of secondary dementia and the second most common of all dementias. The present paper aims to define guidelines on the basic principles for treating patients with suspected VaD (and vascular cognitive impairment - no dementia) using an evidence-based approach. The material was retrieved and selected from searches of databases (Medline, Scielo, Lilacs), preferentially from the last 15 years, to propose a systematic way to assess cognition, function and behavior, and disease severity staging, with instruments adapted for our milieu, and diagnosis disclosure. The present proposal contributes to the definition of standard diagnostic criteria for VaD based on various levels of evidence. It is noteworthy that only around half of the population of patients with vascular cognitive impairment present with dementia, which calls for future proposals defining diagnostic criteria and procedures for this condition.

Italian norms for the Freedman version of the Clock Drawing Test

BACKGROUND

The Clock Drawing Test (CDT) is a valid screening tool for the evaluation of cognitive decline. This study aimed to compute standardized norms for the Freedman version of the CDT in a population of 248 healthy Italian individuals aged from 20 to 89 years.

METHOD

The effects of age, education, and gender on performance were assessed. Three conditions were administered: free-drawn clock (FD), which required participants to draw the contour, numbers, hands, and center of the clock; predrawn clock (PD), in which numbers, hands, and center had to be included in a predrawn contour; examiner-drawn clock (ED), in which only hands and center had to be inserted in a template including a predrawn contour and numbers. Scores for each of the single conditions and a total score were calculated.

RESULTS

Age had no effect on the FD condition, whereas a significant effect of age was found for the PD and ED conditions and the total score. Gender and education had no influence on any of the scores. Correction grids, cutoffs, and equivalent scores were computed.

CONCLUSION

Standardized norms for the Freedman version of the CDT were collected in a large sample of healthy individuals. No adjustments were required for scores on the free-drawn condition, whereas raw scores on the predrawn and examiner-drawn conditions and the total score needed adjustments to account for age effects. The availability of standardized norms for this version of the CDT could increase the use of this comprehensive tool in the detection of dementia.

Correlates of level and change in the Mini-Mental State Examination

The goal of the current project was to determine (a) the cognitive abilities assessed by the Mini Mental State Examination (MMSE; M. F. Folstein, S. E. Folstein, & P. R. McHugh, 1975), (b) whether the same abilities are associated with MMSE performance among people of different ages, and (c) whether the same abilities are involved in changes within the same people over time. The authors therefore examined whether the initial levels of 5 cognitive ability constructs (vocabulary, reasoning, memory, space, and speed) predicted initial levels of MMSE performance and whether the initial levels or the changes in these 5 cognitive abilities predicted change in the MMSE performance. The major findings were that 3 cognitive constructs (vocabulary, reasoning, and memory) contribute to performance in the MMSE but that their respective contributions to the MMSE vary as a function of age and time. In particular, individual differences and change in the MMSE are primarily related to individual differences in reasoning among adults younger than about 70 years, whereas both initial level of MMSE performance and longitudinal change in MMSE performance primarily related to initial level and change in memory ability among adults older than 70 years. The results therefore imply that both the level of performance on the MMSE at a single point in time and the change in MMSE over time may represent somewhat different cognitive abilities at different ages.

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: 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.

No-motor impairment in patients with Parkinson’s disease

No-motor symptoms, vesting patients with Parkinson’s disease (PD), predominate at clinical finding of PD. The aim of research was analysis of no-motor disorders against gender the patients with PD. The results of this study have shown that there are not any differences in the age, the age of onset of disease and illness duration between the genders. We have found that the trembling form of PD, cognitive and anxious disorders appear more often of female then male.

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

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.