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Sejunaite K, Gaucher F, Lanza C, Riepe MW. Clock Drawing Test: Types of Errors and Accuracy in Early Cognitive Screening. J Alzheimers Dis 2023; 95:1597-1608. [PMID: 37718798 DOI: 10.3233/jad-230110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
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.
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Affiliation(s)
- Karolina Sejunaite
- Department of Psychiatry and Psychfapy II Mental Health & Old Age Psychiatry, Ulm University, Ulm, Germany
| | - Frederic Gaucher
- Department of Psychiatry and Psychfapy II Mental Health & Old Age Psychiatry, Ulm University, Ulm, Germany
| | - Claudia Lanza
- Department of Psychiatry and Psychfapy II Mental Health & Old Age Psychiatry, Ulm University, Ulm, Germany
| | - Matthias W Riepe
- Department of Psychiatry and Psychfapy II Mental Health & Old Age Psychiatry, Ulm University, Ulm, Germany
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Kor PPK, Kwan RYC, Cheung DSK, Lai C. The utilization of a nurse-led clinic by older people with cognitive complaints: Do they follow our advice? Int J Nurs Pract 2022; 28:e13096. [PMID: 36003029 DOI: 10.1111/ijn.13096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 06/08/2022] [Accepted: 07/23/2022] [Indexed: 12/01/2022]
Abstract
AIM Cognitive assessment services were found to be beneficial to older people with cognitive complaints but information is limited on adherence to the recommendations provided. This study aimed to identify predictors of clients' adherence to nursing recommendations after attending a community-based nurse-led cognitive assessment service in Hong Kong. METHODS A cross-sectional design was adopted. We analysed a dataset routinely collected from clients attending the services between January 2012 and January 2018. Multiple regression analyses were conducted to identify predictors (demographics, functional health status and cognitive performance) of the clients' adherence. Their satisfaction with the services was also examined. RESULTS Two hundred and twenty-three clients attended the clinic. Of the 133 who completed the telephone follow-up at the 6 months postconsultation, 44.1% did not adhere to the recommendations. Clients with a higher Clinical Dementia Rating (OR = 4.17), lower Clock Drawing Test score (OR = 1.13) and lower education level (OR = 0.91) were found to be less likely to adhere to the nursing recommendations. Ninety-six percent (190/198) were satisfied with the overall services. CONCLUSION Cognitive assessment services in nurse-led clinics could provide a self-referred service for older people with cognitive complaints. However, low adherence to nursing recommendations was found among clients with poorer cognitive functions and lower education levels.
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Affiliation(s)
- Patrick Pui-Kin Kor
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong, SAR, China
| | | | | | - Claudia Lai
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong, SAR, China
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3
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Abstract
This study presents a systematic review on existing cognitive screening tools for mild cognitive impairment and dementia in populations with low education and literacy levels. Cochrane Library, PubMed and LILACS databases were examined for studies including adults aged 50 years old or older with low educational level. 61 articles were included. Despite its frequent use, studies on Mini-Mental State Examination (MMSE) revealed that educational level biased the score obtained, regardless of other factors. Separately, the Informant Questionnaire on Cognitive Decline in the Elderly, the Fototest, or the Eurotest, appear to minimize the effect of education and literacy. MMSE is unreliable for individuals with low literacy. Tasks involving reading, writing, arithmetics, drawing, praxis, visuospatial, and visuoconstructive skills have a greater educational bias than naming, orientation, or memory. An adequate determination of educational level and validation of instruments in populations with heterogeneous levels of literacy requires further research.
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Affiliation(s)
| | - Unai Díaz-Orueta
- Department of Psychology, Maynooth University, Maynooth, Ireland
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4
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Advinha AM, Nunes C, de Barros CT, Lopes MJ, de Oliveira-Martins S. Key factors of the functional ability of older people to self-manage medications. Sci Rep 2021; 11:22196. [PMID: 34772959 PMCID: PMC8590057 DOI: 10.1038/s41598-021-01434-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022] Open
Abstract
Daily medication use can be affected by the gradual loss of functional ability. Thus, elderly patients are at risk for nonadherence due to functional decline, namely, decreases in cognitive skills and visual and manual dexterity. The main objective was to assess the ability of older people to self-manage their medication and to identify the main predictors for unintentional nonadherence. A cross-sectional study was conducted (2014-2017) in community centers and pharmacies. Functional assessment was performed with the Portuguese versions of the Drug Regimen Unassisted Grading Scale (DRUGS-PT) and the Self-Medication Assessment Tool (SMAT-PT). A purposive sample including 207 elderly patients was obtained. To identify the main predictors, binary logistic regression was performed. The average DRUGS-PT score was slightly lower than that in other studies. On the SMAT-PT, the greatest challenge for patients was identifying medications by reading labels/prescriptions. The main difficulties identified were medication memorization and correct schedule identification. The scores were higher with the real regimen than with the simulated regimen, underlining the difficulties for patients in receiving new information. Regarding the predictors of an older individual's ability to self-manage medications, two explanatory models were obtained, with very high areas under the curve (> 90%). The main predictors identified were cognitive ability, level of schooling and daily medication consumption.
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Affiliation(s)
- Ana Margarida Advinha
- CHRC - Comprehensive Health Research Centre, Lisbon, Portugal.
- Universidade de Évora, Évora, Portugal.
| | - Carla Nunes
- CHRC - Comprehensive Health Research Centre, Lisbon, Portugal
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | - Manuel José Lopes
- CHRC - Comprehensive Health Research Centre, Lisbon, Portugal
- Universidade de Évora, Évora, Portugal
| | - Sofia de Oliveira-Martins
- CHRC - Comprehensive Health Research Centre, Lisbon, Portugal
- Faculdade de Farmácia, Universidade de Lisboa, Lisbon, Portugal
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5
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Yap KH, Kessels RPC, Azmin S, van de Warrenburg B, Mohamed Ibrahim N. Neurocognitive Changes in Spinocerebellar Ataxia Type 3: A Systematic Review with a Narrative Design. Cerebellum 2021; 21:314-327. [PMID: 34231180 DOI: 10.1007/s12311-021-01282-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Kah Hui Yap
- Department of Medicine, UKM Medical Center, 56000, Kuala Lumpur, Malaysia
| | - Roy P C Kessels
- Donders Institute for Brain, Cognition and Behavior, Radboud University, PO Box 9104, 6500 HE, Nijmegen, The Netherlands.,Department of Medical Psychology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.,Vincent Van Gogh Institute for Psychiatry, Venray, The Netherlands
| | - Shahrul Azmin
- Department of Medicine, UKM Medical Center, 56000, Kuala Lumpur, Malaysia
| | - Bart van de Warrenburg
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Tang JY, Luo H, Tse M, Lum TY, Wong GH, Li SX. The relationship between insomnia symptoms and frailty in community-dwelling older persons: a path analysis. Sleep Med 2021; 84:237-43. [PMID: 34175659 DOI: 10.1016/j.sleep.2021.05.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/02/2021] [Accepted: 05/31/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The relationship between sleep and frailty in older age is complex. Most previous studies focused on sleep duration, while insomnia, a common sleep problem in older adults, has not been adequately examined and the factors implicated in its association with frailty were under-explored. METHODS A community-based sample of 345 prefrail and frail older adults were recruited and completed the measures on insomnia symptoms (Pittsburgh Sleep Quality Index) and frailty status (FRAIL Scale). The relationship between insomnia symptoms and frailty, with potential mediators including physical performance (Short Physical Performance Battery), depression (Patient Health Questionnaire-9), and level of physical activity (Physical Activity Scale for the Elderly), were tested in path analysis adjusting for age, gender, body mass index and sleep medications. RESULTS The prevalence of sleep-onset insomnia was higher in frail participants than their prefrail counterparts (48% vs. 34%, aOR = 1.73; 95% CI 1.09, 2.76; p = 0.02), but there was no significant difference in the prevalence of sleep-maintenance insomnia (61% vs. 54%). The association between sleep-onset insomnia and frailty was explained by reduced physical performance (standardized coefficient = 0.11; 95% BCa CI [0.002, 0.233]), but not depression and level of physical activity. Sleep-maintenance insomnia was not associated with frailty. CONCLUSIONS Insomnia symptoms are prevalent in frail and prefrail older adults. Sleep-onset insomnia is associated with poorer physical performance, which is further linked to a higher risk for frailty in older persons. The findings highlight the importance of timely assessing and managing insomnia among older adults at risk of frailty.
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Shao K, Dong FM, Guo SZ, Wang W, Zhao ZM, Yang YM, Wang PP, Wang JH. 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. Brain Behav 2020; 10:e01806. [PMID: 32856405 PMCID: PMC7667341 DOI: 10.1002/brb3.1806] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Kai Shao
- Department of Graduate College, Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Fang-Ming Dong
- Department of Graduate College, Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Shang-Zun Guo
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China.,Department of Graduate College, Hebei North University, Zhangjiakou, China
| | - Wei Wang
- Department of Graduate College, Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Zhong-Min Zhao
- Department of Graduate College, Hebei Medical University, Shijiazhuang, China.,Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Yi-Ming Yang
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China.,Department of Graduate College, Hebei North University, Zhangjiakou, China
| | - Pan-Pan Wang
- Department of Electromyography, Hebei General Hospital, Shijiazhuang, China
| | - Jian-Hua Wang
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
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Ilardi CR, Garofalo E, Chieffi S, Gamboz N, La Marra M, Iavarone A. Daily exposure to digital displays may affect the clock-drawing test: from psychometrics to serendipity. Neurol Sci 2020; 41:3683-90. [PMID: 32506359 DOI: 10.1007/s10072-020-04498-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/30/2020] [Indexed: 10/24/2022]
Abstract
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.
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Franzen S, van den Berg E, Goudsmit M, Jurgens CK, van de Wiel L, Kalkisim Y, Uysal-Bozkir Ö, Ayhan Y, Nielsen TR, Papma JM. A Systematic Review of Neuropsychological Tests for the Assessment of Dementia in Non-Western, Low-Educated or Illiterate Populations. J Int Neuropsychol Soc 2020; 26:331-51. [PMID: 31511111 DOI: 10.1017/S1355617719000894] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neuropsychological tests are important instruments to determine a cognitive profile, giving insight into the etiology of dementia; however, these tests cannot readily be used in culturally diverse, low-educated populations, due to their dependence upon (Western) culture, education, and literacy. In this review we aim to give an overview of studies investigating domain-specific cognitive tests used to assess dementia in non-Western, low-educated populations. The second aim was to examine the quality of these studies and of the adaptations for culturally, linguistically, and educationally diverse populations. METHOD A systematic review was performed using six databases, without restrictions on the year or language of publication. RESULTS Forty-four studies were included, stemming mainly from Brazil, Hong Kong, Korea, and considering Hispanics/Latinos residing in the USA. Most studies focused on Alzheimer's disease (n = 17) or unspecified dementia (n = 16). Memory (n = 18) was studied most often, using 14 different tests. The traditional Western tests in the domains of attention (n = 8) and construction (n = 15), were unsuitable for low-educated patients. There was little variety in instruments measuring executive functioning (two tests, n = 13), and language (n = 12, of which 10 were naming tests). Many studies did not report a thorough adaptation procedure (n = 39) or blinding procedures (n = 29). CONCLUSIONS Various formats of memory tests seem suitable for low-educated, non-Western populations. Promising tasks in other cognitive domains are the Stick Design Test, Five Digit Test, and verbal fluency test. Further research is needed regarding cross-cultural instruments measuring executive functioning and language in low-educated people.
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Shanhu X, Linhui C, Xiaoqing J, Jing Y, Saizhu X, Ying X, Caixia L, Yu J. Effects of age and education on clock-drawing performance by elderly adults in China. Clin Neuropsychol 2019; 33:96-105. [PMID: 31322036 DOI: 10.1080/13854046.2019.1640285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Xu Shanhu
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Chen Linhui
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Jin Xiaoqing
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Yan Jing
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Xu Saizhu
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Xu Ying
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Liu Caixia
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Jin Yu
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
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Pagliai G, Sofi F, Dinu M, Sticchi E, Vannetti F, Molino Lova R, Ordovàs JM, Gori AM, Marcucci R, Giusti B, Macchi C. CLOCK gene polymorphisms and quality of aging in a cohort of nonagenarians - The MUGELLO Study. Sci Rep 2019; 9:1472. [PMID: 30728411 DOI: 10.1038/s41598-018-37992-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 11/23/2018] [Indexed: 02/01/2023] Open
Abstract
A total of 356 elderly subjects [257F; 88–106 years] were genotyped for three polymorphisms of the CLOCK gene by TaqMan real-time PCR approach, in order to find associations with quality of aging. Subjects homozygous for the minor allele of rs1801260 were less frequently overweight (p = 0.046), had higher fasting glucose levels (p = 0.037), better scores at the Clock Drawing Test (CDT) (p = 0.047) and worse scores at the Geriatric Depression Scale (p = 0.032). Subjects homozygous for the minor allele of rs11932595 showed higher fasting glucose levels (p = 0.044) and better scores at CDT (p = 0.030). Conversely, subjects homozygous for the minor allele of rs4580704 showed higher triglyceride (p = 0.012), and LDL-cholesterol levels (p = 0.44), and a greater adherence to the Mediterranean diet (MD) (p = 0.044). In addition, AAC, AAG, GGC and AGC (rs1801260–rs11932595–rs4580704) haplotypes were analyzed: AAG was associated with higher risk of overweight (p = 0.008), hypertriglyceridemia (p = 0.040) and hypercholesterolemia (p = 0.036); GGC with lower risk of hyperglycemia (p = 0.022), better sleep pattern (p = 0.001) and with better score at mini-mental state examination (p = 0.010); AGC with lower risk of depression (p = 0.026) and AAC with lower adherence to the MD (p = 0.028). Therefore, CLOCK gene polymorphisms let us hypothesize an involvement in the quality of aging in a cohort of nonagenarians.
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Kim S, Jahng S, Yu KH, Lee BC, Kang Y. Usefulness of the Clock Drawing Test as a Cognitive Screening Instrument for Mild Cognitive Impairment and Mild Dementia: an Evaluation Using Three Scoring Systems. Dement Neurocogn Disord 2018; 17:100-9. [PMID: 30906399 DOI: 10.12779/dnd.2018.17.3.100] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/07/2018] [Accepted: 11/20/2018] [Indexed: 11/27/2022] Open
Abstract
Background and Purpose Although the clock drawing test (CDT) is a widely used cognitive screening instrument, there have been inconsistent findings regarding its utility with various scoring systems in patients with mild cognitive impairment (MCI) or dementia. The present study aimed to identify whether patients with MCI or dementia exhibited impairment on the CDT using three different scoring systems, and to determine which scoring system is more useful for detecting MCI and mild dementia. Methods Patients with amnestic mild cognitive impairment (aMCI), vascular mild cognitive impairment (VaMCI), mild Alzheimer's disease (AD), mild vascular dementia (VaD), and cognitively normal older adults (CN) were included. All participants were administered the CDT, the Korean-Mini Mental State Examination (K-MMSE), and the Clinical Dementia Rating scale. The CDT was scored using the 3-, 5-, and 15-point scoring systems. Results On all three scoring systems, all patient groups demonstrated significantly lower scores than the CN. However, while there were no significant differences among patients with aMCI, VaMCI, and AD, those with VaD exhibited the lowest scores. Area under the Receiver Operating Characteristic curves revealed that the three CDT scoring systems were comparable with the K-MMSE in differentiating aMCI, VaMCI, and VaD from CN. In differentiating AD from CN, however, the CDT using the 15-point scoring system demonstrated the most comparable discriminability with K-MMSE. Conclusions The results demonstrated that the CDT is a useful cognitive screening tool that is comparable with the Mini-Mental State Examination, and that simple CDT scoring systems are sufficient for differentiating patients with MCI and mild dementia from CN.
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Chiu HFK, Zhong BL, Leung T, Li SW, Chow P, Tsoh J, Yan C, Xiang YT, Wong M. Development and validation of a new cognitive screening test: The Hong Kong Brief Cognitive Test (HKBC). Int J Geriatr Psychiatry 2018; 33:994-999. [PMID: 29642275 DOI: 10.1002/gps.4883] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 01/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To develop and examine the validity of a new brief cognitive test with less educational bias for screening cognitive impairment. METHODS A new cognitive test, Hong Kong Brief Cognitive Test (HKBC), was developed based on review of the literature, as well as the views of an expert panel. Three groups of subjects aged 65 or above were recruited after written consent: normal older people recruited in elderly centres, people with mild NCD (neurocognitive disorder), and people with major NCD. The brief cognitive test, Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment Scale (MoCA), were administered to the subjects. The performance of HKBC in differentiating subjects with major NCD, mild NCD, and normal older people were compared with the clinical diagnosis, as well as the MMSE and MoCA scores. RESULTS In total, 359 subjects were recruited, with 99 normal controls, 132 subjects with major NCD, and 128 with mild NCD. The mean MMSE, MoCA, and HKBC scores showed significant differences among the 3 groups of subjects. In the receiving operating characteristic curve analysis of the HKBC in differentiating normal subjects from those with cognitive impairment (mild NCD + major NCD), the area under the curve was 0.955 with an optimal cut-off score of 21/22. The performances of MMSE and MoCA in differentiating normal from cognitively impaired subjects are slightly inferior to the HKBC. CONCLUSIONS The HKBC is a brief instrument useful for screening cognitive impairment in older adults and is also useful in populations with low educational level.
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Affiliation(s)
- Helen F K Chiu
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong
| | - Bao-Liang Zhong
- Affiliated Mental Health Center, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Tony Leung
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong
| | - S W Li
- Castle Peak Hospital, Hong Kong
| | | | | | | | - Yu-Tao Xiang
- Faculty of Health Sciences, University of Macau, Macau, China
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Palsetia D, Rao GP, Tiwari SC, Lodha P, De Sousa A. The Clock Drawing Test versus Mini-mental Status Examination as a Screening Tool for Dementia: A Clinical Comparison. Indian J Psychol Med 2018; 40:1-10. [PMID: 29403122 PMCID: PMC5795671 DOI: 10.4103/ijpsym.ijpsym_244_17] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
There is a growing incidence of dementia patients in the community, and with this growth, there is need for rapid, valid, and easily administrable tests for the screening of dementia and mild cognitive impairment in the community. This review looks at the two most commonly used tests in dementia screening, namely, the clock drawing test (CDT) and the mini-mental status examination (MMSE). Both these tests have been used in dementia screening over the past three decades and have been the subject of scrutiny of various studies, reviews, and meta-analysis. Both these tests are analyzed on their ability to assess dementia and screen for it in the community, general practice and general hospital settings. The methods of administration and scoring of each test are discussed, and their advantages and disadvantages are explained. There is also a direct comparison made between the MMSE and CDT in dementia screening. Future research needs with these tests are also elucidated.
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Affiliation(s)
- Delnaz Palsetia
- Department of Psychiatry, Asha Hospital, Hyderabad, Telangana, India
| | - G. Prasad Rao
- Department of Psychiatry, Asha Hospital, Hyderabad, Telangana, India
| | - Sarvada C. Tiwari
- Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Pragya Lodha
- Department of Research Assistant, Desousa Foundation, Mumbai, Maharashtra, India
| | - Avinash De Sousa
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
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Pagliai G, Sofi F, Vannetti F, Caiani S, Pasquini G, Molino Lova R, Cecchi F, Sorbi S, Macchi C. Mediterranean Diet, Food Consumption and Risk of Late-Life Depression: The Mugello Study. J Nutr Health Aging 2018; 22:569-574. [PMID: 29717755 DOI: 10.1007/s12603-018-1019-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To investigate eating habits and adherence to Mediterranean Diet (MD) in relation to the risk of depression in a cohort of nonagenarians enrolled within the Mugello Study, an epidemiological study aimed at investigating both clinically relevant geriatric items and various health issues, including those related to nutritional status. DESIGN Cross-sectional study. SETTING Homes and nursing homes in the Mugello area, Florence, Italy. PARTICIPANTS Subjects aged 90-99 years [N=388 (271F; 117M) mean age: 92.7±3.1]. MEASUREMENTS All subjects were evaluated through questionnaires and instrumental examinations. Adherence to MD was assessed through the Mediterranean Diet Score. A shorter version of the Geriatric Depression Scale (GDS) was used to detect the possible presence of depressive symptoms. In addition, cognitive and functional status was assessed using the Mini-Mental State Examination, the Clock Drawing Test, as well as the Basic and Instrumental Activities of Daily Living test. RESULTS Depressed subjects (DS) (GDS score≥5, 43.8%) were older, females and widows, than non-depressed subjects (NDS). DS reported a slightly but not statistically significant lower MD score than NDS (33.9±3.9 vs. 34.6±3.3, p=0.149). Subjects who reported to consume a greater amount of olive oil and fruit were associated with a lower risk of depression (OR=0.35, 95%CI=0.20-0.59, p<0.001 and OR=0.46, 95%CI=0.26-0.84, p=0.011, respectively) after adjustment for many possible confounders. Similar results were obtained for women, while no statistically significant differences emerged for men. CONCLUSION Our results support the hypothesis that a diet rich in olive oil and fruit, characteristics of MD, may protect against the development of depressive symptoms in older age.
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Affiliation(s)
- G Pagliai
- Giuditta Pagliai, Department of Experimental and Clinical Medicine, University of Florence, Italy, Largo Brambilla 3, 50134, Florence, Italy, Phone: 0557947510,
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Abstract
OBJECTIVE The clock drawing test (CDT) has become one of the most widely used cognitive screening instruments in clinical and research settings. Its effectiveness, acceptability, and quick and easy administration have made it a staple for cognitive screening in dementia and a wide range of brain disorders. Despite a spike in popularity since the 1990s, its origins are relatively unknown. The goal of this review is to chronicle its saga and chart its usage over time. METHODS PsycInfo, Medline, and PubMed literature searches were performed from earliest record to June 2016, in addition to manual cross-referencing of bibliographies, with a focus before 1990. Summary of relevant articles and books up until 1989 is included, as well as clinical applications and surveys that track CDT usage over time. RESULTS While MacDonald Critchley's well-known textbook from 1953, The Parietal Lobes, is often cited as the first mention of the CDT, its recorded use actually stretches back more than a century to 1915. A review of the literature shows that the CDT began as a test for aphasia-related disorders and constructional apraxia until its entry into contemporary cognitive screening in the 1980s when it primarily became a cognitive screen. Its usage took off in 1989 with over 2000 publications since. CONCLUSIONS Despite a fairly obscure existence for decades, the CDT has emerged as an effective and ideal cognitive screening instrument for a wide range of conditions. Its use continues to increase, and it has been incorporated into several widely used cognitive screening batteries. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Elias Hazan
- Department of Psychiatry, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Frances Frankenburg
- Department of Psychiatry, Edith Nourse Rogers Memorial Veterans Administration Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Megan Brenkel
- Department of Psychiatry, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Kenneth Shulman
- Department of Psychiatry, Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Paddick SM, Gray WK, McGuire J, Richardson J, Dotchin C, Walker RW. Cognitive screening tools for identification of dementia in illiterate and low-educated older adults, a systematic review and meta-analysis. Int Psychogeriatr 2017; 29:897-929. [PMID: 28274299 DOI: 10.1017/S1041610216001976] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The majority of older adults with dementia live in low- and middle-income countries (LMICs). Illiteracy and low educational background are common in older LMIC populations, particularly in rural areas, and cognitive screening tools developed for this setting must reflect this. This study aimed to review published validation studies of cognitive screening tools for dementia in low-literacy settings in order to determine the most appropriate tools for use. METHOD A systematic search of major databases was conducted according to PRISMA guidelines. Validation studies of brief cognitive screening tests including illiterate participants or those with elementary education were eligible. Studies were quality assessed using the QUADAS-2 tool. Good or fair quality studies were included in a bivariate random-effects meta-analysis and a hierarchical summary receiver operating characteristic (HSROC) curve constructed. RESULTS Forty-five eligible studies were quality assessed. A significant proportion utilized a case-control design, resulting in spectrum bias. The area under the ROC (AUROC) curve was 0.937 for community/low prevalence studies, 0.881 for clinic based/higher prevalence studies, and 0.869 for illiterate populations. For the Mini-Mental State Examination (MMSE) (and adaptations), the AUROC curve was 0.853. CONCLUSION Numerous tools for assessment of cognitive impairment in low-literacy settings have been developed, and tools developed for use in high-income countries have also been validated in low-literacy settings. Most tools have been inadequately validated, with only MMSE, cognitive abilities screening instrument (CASI), Eurotest, and Fototest having more than one published good or fair quality study in an illiterate or low-literate setting. At present no screening test can be recommended.
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Abstract
The Clock Drawing Test (CDT) is a simple neuropsychological screening instrument
that is well accepted by patients and has solid psychometric properties. Several
different CDT scoring methods have been developed, but no consensus has been
reached regarding which scoring method is the most accurate. This article
reviews the literature on these scoring systems and the changes they have
undergone over the years. Historically, different types of scoring systems
emerged. Initially, the focus was on screening for dementia, and the methods
were both quantitative and semi-quantitative. Later, the need for an early
diagnosis called for a scoring system that can detect subtle errors, especially
those related to executive function. Therefore, qualitative analyses began to be
used for both differential and early diagnoses of dementia. A widely used
qualitative method was proposed by Rouleau et al. (1992). Tracing the historical
path of these scoring methods is important for developing additional scoring
systems and furthering dementia prevention research.
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Affiliation(s)
- Bárbara Spenciere
- BsC, Department of Psychology, Pontifical Catholic University of Rio de Janeiro RJ - Brazil
| | - Heloisa Alves
- PhD, Department of Psychology, Pontifical Catholic University of Rio de Janeiro RJ - Brazil
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Siciliano M, Santangelo G, D’Iorio A, Basile G, Piscopo F, Grossi D, Trojano L. Rouleau version of the Clock Drawing Test: age- and education-adjusted normative data from a wide Italian sample. Clin Neuropsychol 2016; 30:1501-1516. [DOI: 10.1080/13854046.2016.1241893] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tang JYM, Wong GHY, Ng CKM, Kwok DTS, Lee MNY, Dai DLK, Lum TYS. Neuropsychological Profile and Dementia Symptom Recognition in Help-Seekers in a Community Early-Detection Program in Hong Kong. J Am Geriatr Soc 2016; 64:584-9. [PMID: 26928890 DOI: 10.1111/jgs.13938] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the neuropsychological and clinical profile of help-seekers in an early-detection community dementia program and to explore any relationship between profiles and time to seek help. DESIGN Cross-sectional. SETTING Early-detection community dementia program. PARTICIPANTS Help-seekers (N = 1,005) with subjective cognitive complaints or complaints from an informant. MEASUREMENTS Neurocognitive testing, including the Cantonese Mini-Mental State Examination (MMSE), Clock Drawing Test, Digit Span, and Fuld Object Memory Evaluation and other clinical and functioning assessments, including the Clinical Dementia Rating (CDR), activities of daily living (ADLs), instrumental ADLs (IADLs), and depressive symptoms. Time since the person or an informant reported that they first noticed symptoms. RESULTS Eighty-six percent of help-seekers had at least very mild dementia (CDR score ≥0.5). Cognitive performance was moderately impaired (mean MMSE score 18.4 ± 6.1). They required some assistance with IADLs, had very mild ADL impairments, and had few depressive symptoms. Median time to seek assessment was 12 months (interquartile range 7-30 months) according to the person or the informant (an adult child in 75% of the sample). Using the median-split method, time to seek assessment was classified as early (0-12 months) and late (>12 months). Worse cognitive and IADL performance but not ADL performance or depressive symptoms were observed in late than in early help-seekers. Longer time intervals between symptom recognition and early assessment showed a trend of further impairments on all measures except ADLs. CONCLUSION A time interval of more than 12 months between symptom recognition and early assessment appears to be associated with worse cognitive function upon presentation.
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Affiliation(s)
| | - Gloria H-Y Wong
- Sau Po Centre on Ageing, University of Hong Kong, Hong Kong.,Department of Psychiatry, LKS Faculty of Medicine, University of Hong Kong, Hong Kong.,Department of Social Work and Social Administration, University of Hong Kong, Hong Kong.,Hong Kong Alzheimer's Disease Association, Hong Kong
| | - Carmen K-M Ng
- Department of Social Work and Social Administration, University of Hong Kong, Hong Kong
| | | | | | - David L-K Dai
- Sau Po Centre on Ageing, University of Hong Kong, Hong Kong.,Hong Kong Alzheimer's Disease Association, Hong Kong.,Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong
| | - Terry Y-S Lum
- Sau Po Centre on Ageing, University of Hong Kong, Hong Kong.,Department of Social Work and Social Administration, University of Hong Kong, Hong Kong
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Mazancova AF, Nikolai T, Stepankova H, Kopecek M, Bezdicek O. The Reliability of Clock Drawing Test Scoring Systems Modeled on the Normative Data in Healthy Aging and Nonamnestic Mild Cognitive Impairment. Assessment 2016; 24:945-957. [DOI: 10.1177/1073191116632586] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Clock Drawing Test (CDT) is a commonly used tool in clinical practice and research for cognitive screening among older adults. The main goal of the present study was to analyze the interrater reliability of three different CDT scoring systems (by Shulman et al., Babins et al., and Cohen et al.). We used a clock with a predrawn circle. The CDT was evaluated by three independent raters based on the normative data set of healthy older and very old adults and patients with nonamnestic mild cognitive impairment (naMCI; N = 438; aged 61-94). We confirmed a high interrater reliability measured by the intraclass correlation coefficients (ICCs): Shulman ICC = .809, Babins ICC = .894, and Cohen ICC = .862, all p < .001. We found that age and education levels have a significant effect on CDT performance, yet there was no influence of gender. Finally, the scoring systems differentiated between naMCI and age- and education-matched controls: Shulman’s area under the receiver operating characteristic curve (AUC) = .84, Cohen AUC = .71, all p < .001; and a slightly lower discriminative ability was shown by Babins: AUC = .65, p = .012.
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Affiliation(s)
- Adela Fendrych Mazancova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital in Prague, Charles University in Prague, Prague, Czech Republic
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
| | - Tomas Nikolai
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital in Prague, Charles University in Prague, Prague, Czech Republic
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
| | - Hana Stepankova
- National Institute of Mental Health, Klecany, Czech Republic
| | | | - Ondrej Bezdicek
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine and General University Hospital in Prague, Charles University in Prague, Prague, Czech Republic
- National Institute of Mental Health, Klecany, Czech Republic
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22
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Ricci M, Pigliautile M, D’ambrosio V, Ercolani S, Bianchini C, Ruggiero C, Vanacore N, Mecocci P. The clock drawing test as a screening tool in mild cognitive impairment and very mild dementia: a new brief method of scoring and normative data in the elderly. Neurol Sci 2016; 37:867-73. [DOI: 10.1007/s10072-016-2480-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/09/2016] [Indexed: 10/22/2022]
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Abstract
BACKGROUND The prevalence of dementia is increasing in Asia than in any other continent. However, the applicability of the existing cognitive assessment tools is limited by differences in educational and cultural factors in this setting. We conducted a systematic review of published studies on cognitive assessments tools in Asia. We aimed to rationalize the results of available studies which evaluated the validity of cognitive tools for the detection of cognitive impairment and to identify the issues surrounding the available cognitive impairment screening tools in Asia. METHODS Five electronic databases (CINAHL, MEDLINE, Embase, Cochrane Library, and Science Direct) were searched using the keywords dementia Or Alzheimer Or cognitive impairment And screen Or measure Or test Or tool Or instrument Or assessment, and 2,381 articles were obtained. RESULTS Thirty-eight articles, evaluating 28 tools in seven Asian languages, were included. Twenty-nine (76%) of the studies had been conducted in East Asia with only four studies conducted in South Asia and no study from northern, western, or central Asia or Indochina. Local language translations of the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were assessed in 15 and six studies respectively. Only three tools (the Korean Dementia Screening Questionnaire, the Picture-based Memory Intelligence Scale, and the revised Hasegawa Dementia Screen) were derived de novo from Asian populations. These tools were assessed in five studies. Highly variable cut-offs were reported for the MMSE (17-29/30) and MoCA (21-26/30), with 13/19 (68%) of studies reporting educational bias. CONCLUSIONS Few cognitive assessment tools have been validated in Asia, with no published validation studies for many Asian nations and languages. In addition, many available tools display educational bias. Future research should include concerted efforts to develop culturally appropriate tools with minimal educational bias.
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Amodeo S, Mainland BJ, Herrmann N, Shulman KI. The Times They Are a-Changin': Clock Drawing and Prediction of Dementia. J Geriatr Psychiatry Neurol 2015; 28:145-55. [PMID: 25319477 DOI: 10.1177/0891988714554709] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 09/17/2014] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Sean Amodeo
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brian J Mainland
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
| | - Nathan Herrmann
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kenneth I Shulman
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Prickett C, Brennan L, Stolwyk R. Examining the relationship between obesity and cognitive function: A systematic literature review. Obes Res Clin Pract 2015; 9:93-113. [DOI: 10.1016/j.orcp.2014.05.001] [Citation(s) in RCA: 228] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 05/05/2014] [Accepted: 05/18/2014] [Indexed: 12/22/2022]
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Chang J, Tse CS, Leung GT, Fung AW, Hau KT, Chiu HF, Lam LC. Bias in discriminating very mild dementia for older adults with different levels of education in Hong Kong. Int Psychogeriatr 2014; 26:995-1010. [PMID: 24571785 DOI: 10.1017/S1041610214000234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Education has a profound effect on older adults' cognitive performance. In Hong Kong, some dementia screening tasks were originally designed for developed population with, on average, higher education. METHODS We compared the screening power of these tasks for Chinese older adults with different levels of education. Community-dwelling older adults who were healthy (N = 383) and with very mild dementia (N = 405) performed the following tasks: Mini-Mental State Examination, Alzheimer's Disease Assessment Scale-Cognitive subscales, Verbal Fluency, Abstract Thinking, and Visual/Digit Span. Logistic regression was used to examine the power of these tasks to predict Clinical Dementia Rating (CDR 0.5 vs. 0). RESULTS Logistic regression analysis showed that while the screening power of the total scores in all tasks was similar for high and low education groups, there were education biases in some items of these tasks. CONCLUSION The differential screening power in high and low education groups was not identical across items in some tasks. Thus, in cognitive assessments, we should exercise great caution when using these potentially biased items for older adults with limited education.
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Abstract
OBJECTIVE The clock drawing test (CDT) is a widely used cognitive screening tool that has been well accepted among clinicians and patients for its ease of use and short administration time. Although there is ample interest in the CDT as a screening instrument, there remains a range of CDT administration and scoring systems with no consensus on which system produces the most valid results while remaining user friendly. The aims of this review are to synthesize the available evidence on CDT scoring systems' effectiveness and to recommend which system is best suited for use at the clinical frontlines. DESIGN A Pubmed literature search was carried out from 2000 to 2013 including manual cross-referencing of bibliographies in order to capture studies published after Shulman's comprehensive review published in 2000. A brief summary of all original scoring systems is included, as well as a review of relevant comparative studies. RESULTS The consensus from multiple comparison studies suggests that increasing the complexity of CDT scoring systems does little to enhance the test's ability to identify significant cognitive impairment. Moreover, increased complexity in scoring adds to the administration time, thereby reducing the test's utility in clinical settings. CONCLUSIONS In comparing scoring systems, no system emerged as consistently superior in terms of predictive validity. The authors conclude that when scoring the CDT as a screening instrument in a primary/general medicine/community setting, simpler is better, and perhaps qualitative assessment of "normal" versus "abnormal" may be sufficient for screening purposes and the establishment of a baseline for follow-up.
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Affiliation(s)
- Brian J Mainland
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
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Yoo DH, Hong DG, Lee JS. The Standardization of the Clock Drawing Test (CDT) for People with Stroke Using Rasch Analysis. J Phys Ther Sci 2014; 25:1587-90. [PMID: 24409026 PMCID: PMC3885845 DOI: 10.1589/jpts.25.1587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/03/2013] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The aim of this study was to standardize the clock drawing test (CDT) for
people with stroke using Rasch analysis. [Subjects and Methods] Seventeen items of the CDT
identified through a literature review were performed by 159 stroke patients. The data was
analyzed with Winstep version 3.57 using the Rasch model to examine the unidimensionality
of the items’ fit, the distribution of the items’ difficulty, and the reliability and
appropriateness of the rating scale. [Result] Ten out of the 159 participations (6.2%)
were considered misfit subjects, and one item of the CDT was determined to be a misfit
item based on Rasch analysis. The rating scales were judged as suitable because the
observed average showed an array of vertical orders and MNSQ values < 2. The separate
index and reliability of the subject (1.98, 0.80) and item (6.45, 0.97) showed relatively
high values. [Conclusion] This study is the first to examine the CDT scale in stroke
patients by Rasch analysis. The CDT is expected to be useful for screening stroke patients
with cognitive problems.
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Affiliation(s)
- Doo Han Yoo
- Department of Occupational Therapy, Chonbuk National University Hospital, Republic of Korea
| | - Deok Gi Hong
- Department of Occupational Therapy, Wonkwang University Oriental Medical Hospital, Republic of Korea
| | - Jae Shin Lee
- Department of Occupational Therapy, Graduate School of Konyang University: 158 Kwanjeo, Seo, Daejeon 302-718, Republic of Korea
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Konagaya Y, Watanabe T, Konagaya M. [Cognitive function screening of community-dwelling elderly people using the clock drawing test -quantitative and qualitative analyses]. Nihon Ronen Igakkai Zasshi 2013; 49:483-90. [PMID: 23269029 DOI: 10.3143/geriatrics.49.483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM The purpose of this study was to evaluate whether the clock drawing test (CDT) is useful to assess the cognitive function of community-dwelling elderly people. We evaluated the CDT as a tool to measure cognitive function by qualitative and quantitative analyses. METHODS A total of 14,949 community-dwelling elderly were invited by mail to undergo cognitive screening by CDT. Of these, 8,815 responded, of which 8,684 were eligible for enrollment. We were also able to determine the educational background of 7,404 of these. There were 3,525 men (age: 73.05±6.20 [mean±standard deviation] years old, duration of education: 11.40±2.81 years) and 3,879 women (73.67±6.66, 10.34±2.19) . The drawn clocks were evaluated using the Freedman method, and those clocks drawn with obvious errors such as no circle, numbers, or hands were recorded and analyzed. In addition, any vertical deviation from the center points was also evaluated. RESULTS The recorded percentages of the subjects who correctly completed the individual clock drawing test components varied. The mean total scores were 14.16±1.67 in men and 14.40±1.36 in women. The percentages of subjects with total scores of less than 13 were 16.09% in men and 11.7% in women. The percentage of subjects who made obvious errors was 3.24%, whose total points were significantly lower than those of the subjects who did not. Approximately half of all subjects showed vertical deviation from the center of the clock, and the percentage of upper deviation was greater than that of lower deviation. CONCLUSION CDT is useful to assess the cognitive function of community-dwelling elderly people, and it is also helpful to determine subjects with a potential risk of cognitive impairments.
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Affiliation(s)
- Yoko Konagaya
- Division of Research, Obu Dementia Care Research and Training Center, Japan
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Terranova C, Cardin F, Pietra LD, Zen M, Bruttocao A, Militello C. Ethical and medico-legal implications of capacity of patients in geriatric surgery. Med Sci Law 2013; 53:166-171. [PMID: 23842478 DOI: 10.1177/0025802412473963] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES The aim of this study was to assess the decision-making capacity of elderly patients hospitalized in a geriatric surgery division, and the clinician's ability to assess that capacity. SUBJECTS AND METHODS The study was conducted on patients (aged >66 years) undergoing surgical procedures. Exclusion criteria were a diagnosis of psychogeriatric disorders interfering with decision-making capacity; hearing or visual impairment; and inability to communicate. Patients previously declared legally incompetent were also excluded. The methodological approach consisted of additional interviews to collect data on patients' awareness of the reasons for their hospitalization, their informed consent, and their ability to sign a consent form. The interview was integrated with a clinical-behavioral assessment by means of the Mini-Mental State Examination and the Clock Drawing Test. Data were collected anonymously. RESULTS The inclusion criteria were met by 123 patients, with a mean age ± SD of 77.65 ± 7.91 years (range 67-98). Their mean (±SD) Mini-Mental State Examination and the Clock Drawing Test scores were 24.53 ± 4.29 and 5.36 ± 2.41, respectively. Mild-to-severe cognitive impairment was identified in 39 patients (31.7%). The consent form was signed by 111 patients (90.25%), including 33 patients (29.72%) with mild-severe cognitive impairment; 18 patients (16.21%) were unaware of the reason for their admission to hospital. DISCUSSION Many factors may interfere with elderly patients' ability to give their valid consent to treatment, and this study reveals that clinicians may overestimate their patients' decision-making capacity. Physicians should be aware of this problem, and intellectual capacity assessments and/or enhanced consent procedures should be considered when treating elderly patients.
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Affiliation(s)
- Claudio Terranova
- Legal Medicine Unit, Department of Molecular Medicine, Padova University Hospital, Italy.
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Nyborn JA, Himali JJ, Beiser AS, Devine SA, Du Y, Kaplan E, O'Connor MK, Rinn WE, Denison HS, Seshadri S, Wolf PA, Au R. The Framingham Heart Study clock drawing performance: normative data from the offspring cohort. Exp Aging Res 2013; 39:80-108. [PMID: 23316738 DOI: 10.1080/0361073x.2013.741996] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Justin A Nyborn
- Department of Neurology, Boston University School of Medicine, Boston, MA 02118, USA
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Abstract
SummaryThere is a rising prevalence of dementia in line with the continuing demographic transition. More timely diagnosis of dementia is recommended. Brief cognitive tests are useful as they provide a rapid assessment that can indicate the possibility of dementia and identify people for detailed cognitive assessment. Many brief cognitive tests have been developed and practitioners need information in order to select a test that performs well, is acceptable to patients, and is suitable for the relevant care setting. In a structured review, we identified twelve brief cognitive impairment tests, of which six have been sufficiently studied and can be recommended for use in routine care.
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Staplin L, Gish KW, Lococo KH, Joyce JJ, Sifrit KJ. The Maze Test: A significant predictor of older driver crash risk. Accid Anal Prev 2013; 50:483-489. [PMID: 22683280 DOI: 10.1016/j.aap.2012.05.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 04/30/2012] [Accepted: 05/22/2012] [Indexed: 06/01/2023]
Abstract
A study sponsored by the National Highway Traffic Safety Administration performed functional assessments on approximately 700 drivers age 70 and older who presented for license renewal in urban, suburban, and rural offices of the Maryland Motor Vehicle Administration. This volunteer sample received a small compensation for study participation, with an assurance that their license status would not be affected by the results. A comparison with all older drivers who visited the same sites on the same days indicated that the study sample was representative of Maryland older drivers with respect to age and prior driving safety indices. Relationships between drivers' scores on a computer touchscreen version of the Maze Test and prospective crash and serious moving violation experience were analyzed. Results identified specific mazes as highly significant predictors of future safety risk for older drivers, with a particular focus on non-intersection crashes. Study findings indicate that performance on Maze Tests was predictive of prospective crashes and may be useful, as a complement to other, established cognitive screening tools, in identifying at-risk older drivers.
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Affiliation(s)
- Loren Staplin
- TransAnalytics, LLC, 336 West Broad Street, Quakertown, PA 18951, United States.
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Abstract
The Clock Drawing Test (CDT) has been recognized as an effective tool for dementia detection. This study investigated the clock drawing performance of 240 non-demented elderly Korean people with a wide-range of educational levels and 28 patients with mild dementia of the Alzheimer's type (DAT). We examined the effects of demographic factors, including education, and established norms for the elderly population. We found that the educational attainment and literacy status of older people influenced performance on the CDT significantly (p < .001). Furthermore, qualitative error analysis revealed that normal participants with low educational background committed errors similar to errors of the DAT patients. The DAT patients performed significantly worse than the non-demented participants in the CDT Total score (p < .001). However, the CDT has better criterion validity in participants with more than 6 years of education. In conclusion, the CDT performance in older people who are either illiterate or with 6 or less years of education should be interpreted with caution. Conceptual errors in the CDT can be the result of not only dementia but also lack of education.
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Xu GQ, Lan Y, Huang DF, Rao DZ, Pei Z, Chen L, Zeng JS. Visuospatial attention deficit in patients with local brain lesions. Brain Res 2010; 1322:153-9. [PMID: 20132799 DOI: 10.1016/j.brainres.2010.01.072] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 01/25/2010] [Accepted: 01/27/2010] [Indexed: 12/20/2022]
Abstract
The disability of visuospatial attention can lead to poor volitional movement and functional recovery in patients with brain lesions. However, the accurate clinical method to assess visuospatial attention is limited. The frontoparietal network including the posterior parietal cortex and the frontal eye fields has been shown to involve in visuospatial attention. The Attention Network Test provided measures for three different components of visuospatial attention: alerting, orienting and executive control. This study was to probe the deficit and relationship of visuospatial attention using Attention Network Test paradigm in patients with frontoparietal network lesions. During this task, patients responded significantly slower on each cue condition and target type than controls, and showed deficits in the alerting and orienting networks. The efficiency of resolving conflict was decreased in patients with frontal lesions whereas this was increased in patients with parietal lesions. These findings suggest that the frontoparietal network is involved in the alerting and orienting attentional function and the executive function is possibly selectively associated with the frontal lobe. The Attention Network Test paradigm produces sensitive, valid and reliable subject estimates of visuospatial attention function in patients with brain lesions, and may be useful for clinical rehabilitation strategy selection for patients with the frontoparietal network lesions.
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Affiliation(s)
- Guang-Qing Xu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Road II, Guangzhou, 510080 China
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Nair AK, Gavett BE, Damman M, Dekker W, Green RC, Mandel A, Auerbach S, Steinberg E, Hubbard EJ, Jefferson A, Stern RA. Clock drawing test ratings by dementia specialists: interrater reliability and diagnostic accuracy. J Neuropsychiatry Clin Neurosci 2010; 22:85-92. [PMID: 20160214 PMCID: PMC2938787 DOI: 10.1176/jnp.2010.22.1.85] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The authors conducted a study of clock drawing test scoring by dementia specialists to determine interrater reliability and diagnostic accuracy. The authors randomly assigned 25 clocks from each of six predetermined groups based on consensus diagnosis (cognitive comparison subjects, subjects with a memory complaint but with normal neuropsychological testing, subjects with probable and possible mild cognitive impairment, and subjects with possible and probable Alzheimer's disease) to dementia specialists for blinded scoring using a binary yes/no impairment system and a 0-10 scale as subjectively determined by each individual clinician rater. The authors collapsed the six groups into three (comparison subjects, mild cognitive impairment patients, and Alzheimer's disease patients) and analyzed interrater reliability, sensitivity, and specificity for consensus diagnosis of mild cognitive impairment and Alzheimer's disease. The authors found excellent interrater reliability, sensitivity, and specificity for predicting consensus diagnosis. The 0-10 clock drawing test rating scale was more predictive of consensus diagnosis than the binary impairment scale. Based on rating systems, clock drawing test scoring by dementia clinicians had excellent interrater reliability and sensitivity for differentiating the mild Alzheimer's disease subjects from comparison subjects.
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Affiliation(s)
- Anil K Nair
- Alzheimer's Disease Center, Boston University School of Medicine, Boston, USA.
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Woo J. Geriatrics in the Rest of the World. Brocklehurst's Textbook of Geriatric Medicine and Gerontology 2010. [DOI: 10.1016/b978-1-4160-6231-8.10120-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
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.
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Affiliation(s)
- Ivan Aprahamian
- MD, MSc, Psychogeriatric Unit, Laboratory of Neuroscience (LIM 27), Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, SP, Brazil. Gerontology Division, University of Campinas
| | - José Eduardo Martinelli
- MD, MSc, PhD, Assistant Professor, Geriatrics Division, Jundiaí Medical School, Jundiaí, SP, Brazil
| | | | - Mônica Sanches Yassuda
- PhD, Assistant Professor of Gerontology, School of Arts, Sciences and Humanities (EACH), University of São Paulo. Psychogeriatric Unit, Laboratory of Neuroscience (LIM 27), Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
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Hubbard EJ, Santini V, Blankevoort CG, Volkers KM, Barrup MS, Byerly L, Chaisson C, Jefferson AL, Kaplan E, Green RC, Stern RA. Clock drawing performance in cognitively normal elderly. Arch Clin Neuropsychol 2008; 23:295-327. [PMID: 18243644 PMCID: PMC2752157 DOI: 10.1016/j.acn.2007.12.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2007] [Revised: 12/10/2007] [Accepted: 12/12/2007] [Indexed: 11/18/2022] Open
Abstract
The Clock Drawing Test (CDT) is a common neuropsychological measure sensitive to cognitive changes and functional skills (e.g., driving test performance) among older adults. However, normative data have not been adequately developed. We report the distribution of CDT scores using three common scoring systems [Mendez, M. F., Ala, T., & Underwood, K. L. (1992). Development of scoring criteria for the Clock Drawing Task in Alzheimer's Disease. Journal of the American Geriatrics Society, 40, 1095-1099; Cahn, D. A., Salmon, D. P., Monsch, A. U., Butters, N., Wiederholt, W. C., & Corey-Bloom, J. (1996). Screening for dementia of the Alzheimer type in the community: The utility of the Clock Drawing Test. Archives of Clinical Neuropsychology, 11(6), 529-539], among 207 cognitively normal elderly. The systems were well correlated, took little time to use, and had high inter-rater reliability. We found statistically significant differences in CDT scores based on age and WRAT-3 Reading score, a marker of education quality. We present means, standard deviations, and t- and z-scores based on these subgroups. We found that "normal" CDT performance includes a wider distribution of scores than previously reported. Our results may serve as useful comparisons for clinicians wishing to know whether their patients perform in the general range of cognitively normal elderly.
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Affiliation(s)
- Emily J Hubbard
- Alzheimer’s Disease Clinical and Research Program, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Veronica Santini
- Alzheimer’s Disease Clinical and Research Program, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Karin M Volkers
- Institute of Human Movement Sciences, University of Groningen, Netherlands
| | - Melissa S Barrup
- Alzheimer’s Disease Clinical and Research Program, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Laura Byerly
- Alzheimer’s Disease Clinical and Research Program, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Christine Chaisson
- Alzheimer’s Disease Clinical and Research Program, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Angela L Jefferson
- Alzheimer’s Disease Clinical and Research Program, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Edith Kaplan
- Suffolk University, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Robert C Green
- Alzheimer’s Disease Clinical and Research Program, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Robert A Stern
- Alzheimer’s Disease Clinical and Research Program, Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
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Yap PLK, Ng TP, Niti M, Yeo D, Henderson L. Diagnostic Performance of Clock Drawing Test by CLOX in an Asian Chinese population. Dement Geriatr Cogn Disord 2007; 24:193-200. [PMID: 17690551 DOI: 10.1159/000107080] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Clock Drawing Tests are commonly used for cognitive screening, but their clinical utility has not yet been studied in Chinese Singaporeans. We examined the usefulness of a Clock Drawing Test, CLOX, in detecting dementia in our population and explored its performance in the dementia subtypes, Alzheimer's disease (AD), and the vascular composite group (VCG) of AD with cerebrovascular disease and vascular dementia. METHOD CLOX was administered to 73 subjects (49.3%) with dementia and 75 healthy controls (50.7%). Receiver operating characteristic analysis determined the diagnostic accuracy and optimal cut-off scores, stratified by education. Analysis of Variance was used to compare CLOX scores between AD and VCG. RESULTS The diagnostic accuracy (area under the curve) was 84 and 85% for CLOX1 and CLOX2, respectively. Cut-offs at 10 for CLOX1 and 12 for CLOX2 yielded sensitivities of 75.3 and 75%, and specificities of 76 and 80%, respectively. The mean CLOX1 but not CLOX2 scores for AD (8.1) and VCG (5.5) remained significantly different (p = 0.002) after adjustment for the covariates age, gender, education, MMSE and dementia stage. CONCLUSION Our results support CLOX as a valid cognitive screen in Singaporean Chinese with adequate psychometric properties. In addition, CLOX may aid as an adjunct in differentiating AD from dementia with a vascular element, e.g. AD with cerebrovascular disease and vascular dementia.
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Affiliation(s)
- Philip Lin-Kiat Yap
- Gerontological Research Programme, Faculty of Medicine, National University of Singapore, Singapore.
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Bodner T, Delazer M, Kemmler G, Gurka P, Marksteiner J, Fleischhacker WW. Clock drawing, clock reading, clock setting, and judgment of clock faces in elderly people with dementia and depression. J Am Geriatr Soc 2005; 52:1146-50. [PMID: 15209653 DOI: 10.1111/j.1532-5415.2004.52313.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess patient performance on different clock tasks. DESIGN Group comparisons. SETTING A hospital-based memory clinic; inpatient and outpatient memory clinic. PARTICIPANTS Patients with dementia (n=30), patients with depression (n=30), and healthy controls (n=30). MEASUREMENTS General neuropsychological tests, clock drawing tests, and three additional clock tasks: clock reading, clock setting, and judgment of clock faces (each comprising 12 items). RESULTS Demented patients differed significantly from the control and depression groups on all clock tasks; controls and depressed patients differed only in the clock-setting task. A comparison between tasks showed that clock setting was the most difficult, which differentiated best between diagnostic groups. Groups differed not only in overall performance scores, but also in error characteristics. CONCLUSION Overall, study results indicate that clock setting is a sensitive task that may prove to be a valuable tool when screening for dementia.
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Affiliation(s)
- Thomas Bodner
- Department of Biological Psychiatry, Innsbruck University Clinics, Innsbruck, Austria.
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Abstract
OBJECTIVES A clock drawing test scoring system is presented to explore the neuropsychological/neuroanatomic components underlying clock drawing in patients initially diagnosed with Alzheimer disease, ischemic vascular dementia associated with white matter alterations, and Parkinson disease. METHODS Fourteen clock drawing test errors were scored to create 4 clock drawing test subscales that assess different underlying cognitive operations. RESULTS In the command condition, errors on the Time subscale were correlated with impairment on executive control measures. In the copy condition, errors on the Perseveration/Pull to Stimulus subscale was also correlated with executive control measures. Patients presenting with mild (low) magnetic resonance imaging white matter alterations, significant (high) white matter alterations, and Parkinson disease were compared. In the command condition, the low white matter alterations group made fewer total errors than the Parkinson disease group. In the copy condition, the low white matter alterations group made fewer errors on the Time, Spatial Layout, and Perseveration/Pull to Stimulus clock drawing test subscales than the high white matter alterations or Parkinson disease groups. Few differences were noted between the high white matter alterations and Parkinson disease groups. DISCUSSION Our data suggest that heavy demands on executive control associated with the interruption of large-scale cortical-subcortical neural networks underlie impairment in clock drawing in mild dementia.
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Affiliation(s)
- Stephanie Cosentino
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Heinik J, Solomesh I, Berkman P. Correlation between the CAMCOG, the MMSE, and three clock drawing tests in a specialized outpatient psychogeriatric service. Arch Gerontol Geriatr 2004; 38:77-84. [PMID: 14599707 DOI: 10.1016/j.archger.2003.08.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Our objective was to assess the correlation between (1) the Cambridge Cognitive Examination (CAMCOG) (including the Mini-Mental State Examination [MMSE]) score and three clock drawing tests (CDT) and (2) the three CDTs independently, in a specialized outpatient psychogeriatric service. One hundred and fourteen subjects completed a comprehensive evaluation and were allocated to one of the following groups: dementia of the Alzheimer's type (DAT) in 52; vascular dementia (VD) in 36; non-dementia (ND; Mood or Anxiety Disorders) in 26. When the entire sample of patients is considered, all three CDTs used were highly and significantly correlated to the MMSE score, the CAMCOG score, and to each other. In this patient population, these cognitive tests may be interchangeable for providing an initial objective measure of cognitive function. However, when the same correlations were studied in the separate diagnostic groups, in the dementia group (DAT and VD) even though the high correlations between the various CDTs themselves did not change, the correlations between the MMSE score, the CAMCOG score and the CDTs decreased, more evidently in the VD group. This trend became even more conspicuous in the ND group, where some of the above mentioned correlations became non-significant. We hypothesize that in a real clinical situation the clinician initially assumes the role of cognitive "evaluator" (in terms of the total sample) followed by the role of cognitive "monitor" (in relation to specific diagnostic groups). In the first instance, CDTs, the MMSE, and the CAMCOG might be considered interchangeable as an initial objective measure of cognitive dysfunction, while in the second role, different CDTs might be diversely used, presumably supplemented by other cognitive tests and clinical methods.
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Affiliation(s)
- Jeremia Heinik
- Margoletz Psychogeriatric Center, Ichilov Hospital, 6 Weizman Street, Tel-Aviv 64239, Israel.
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Wong A, Mok VCT, Yim P, Fu M, Lam WWM, Yau C, Chan AS, Wong KS. The executive clock drawing task (CLOX) is a poor screening test for executive dysfunction in Chinese elderly patients with subcortical ischemic vascular disease. J Clin Neurosci 2004; 11:493-7. [PMID: 15177391 DOI: 10.1016/j.jocn.2004.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2003] [Indexed: 11/19/2022]
Abstract
Executive dysfunction (ED) is a prominent feature of subcortical ischemic vascular disease. A screening test for ED is lacking among Chinese. The objective of the study is to investigate the validity and reliability of a Chinese version of the Executive clock drawing task (CLOX) in screening ED among Chinese elderly patients with small subcortical infarct (SSI). The Chinese version of CLOX correlated with MMSE, CDRS I/P, and WCST perseverative errors. However, multivariate regression analysis showed that only education (R(2) change=0.22, p < 0.001 ) and MMSE (R(2) change=0.35, p < 0.001), but none of the standard executive function tests, significantly accounted for the variance in the CLOX. Test-retest (r=0.84) and inter-rater reliability (r=0.84) were high for the CLOX. Conclusions. Although the CLOX is reliable, it is not valid in detecting ED in Chinese elderly patients with SSI.
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Affiliation(s)
- Adrian Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
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Abstract
OBJECTIVE To compare brief dementia screening tests as candidates for routine use in primary care practice. METHOD We selected screening tests that met 2 criteria: 1) administration time of 10 minutes or less in studies including individuals with, and without, dementia; and 2) performance characteristics evaluated in at least 1 community or clinical sample of older adults. We compared tests for face validity, sensitivity, and specificity in a clearly defined subject sample; for vulnerability to sociodemographic biases unrelated to dementia; for direct comparison with an accepted standard; for acceptability to patients and doctors; and for brevity and ease of administration, scoring, and interpretation by nonspecialists. RESULTS Thirteen instruments met our inclusion criteria. Very short tests (1 minute or less) proved unacceptable by several criteria. Standard instruments requiring more than 5 minutes to complete, including the best-studied Mini-Mental State Examination (MMSE), were found to be too long for routine application. Several failed other performance tests or could not be adequately assessed. Short tests taking between 2 and 5 minutes that can be administered by nonspecialists with little or no training and are relatively unbiased by language and education level appear to be superior to both shorter and longer instruments. CONCLUSIONS Three tests showed the most promise for broad application in primary care settings: the Mini-Cog, the Memory Impairment Screen, and the General Practitioner Assessment of Cognition (GPCOG). Formal practice intervention trials are now needed to validate the utility of short screens with regard to implementation, effect on rates of diagnosis and treatment of dementia patients, and outcomes for patients, families, and health care systems.
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Affiliation(s)
- Wendy J Lorentz
- University of Washington School of Medicine, Seattle, Washington, USA
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46
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Abstract
BACKGROUND Clock drawing tests (CDTs) vary in format, scoring, and complexity. Herein, we compared the dementia screening performance of seven CDT scoring systems and the judgements of untrained raters. METHODS 80 clock drawings by subjects of known dementia status were selected, 20 from each of four categories (Consortium to Establish a Registry for Alzheimer's disease [CERAD] defined normal, mild, moderate, and severe abnormality). An expert rater scored all clocks using published criteria for seven systems. Additionally, 20 naïve raters judged clocks as either normal or abnormal, without formal instructions. Clocks were then classified by drawers' dementia status for comparison of dementia detection across systems. RESULTS Naïve and formal CDT systems showed 90-100% agreement in CERAD normal, moderate and severe categories, but poor agreement (mean = 39%) for mildly impaired clocks. When CDT systems were compared for accurate dementia classification, the Mendez and CERAD systems correctly identified the greatest proportion of subjects (84-85%), and Wolf-Klein the smallest (58%). The better systems correctly identified> 70% of mildly demented individuals (CDR = 1). In contrast, medical records from patients' personal physicians correctly identified only 24% of the mildly demented. Strikingly, naïve raters' CDT judgements were as effective as five of the seven CDT systems in dementia identification. CONCLUSIONS While the Mendez system was the most accurate overall, it was not significantly better than CERAD, which had simpler scoring rules. Untrained raters discriminated normal from abnormal clocks with acceptable accuracy for community screening purposes. Results suggest that, if used, most CDT systems would improve personal physicians' dementia recognition in difficult to detect mildly demented subjects.
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Affiliation(s)
- James M Scanlan
- Alzheimer's Disease Research Center, University of Washington, Seattle 98195-6560, USA.
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Abstract
Although quantitative analyses of clock drawings (CD) have achieved widespread clinical use as a cognitive screening, little is known about the qualitative profiles of CD in Alzheimer's disease (AD) and vascular dementia (VD). To address this issue, the present study examined the significance of qualitative analyses of CD in AD and VD. Sixty-seven AD patients, 44 VD patients and eight controls underwent a clock drawing test and took the Mini-Mental State Examinations (MMSE). In the dementia groups, quantitative scores significantly decreased compared with controls and were significantly correlated with MMSE scores. Qualitative analysis demonstrated that in AD patients qualitative error patterns were stable and independent of severity. In contrast, in VD patients the frequency of graphic difficulties and conceptual deficit increased, while the frequency of spatial and/or planning deficit decreased, as severity worsened. In mild dementia groups the frequency of spatial and/or planning deficit was significantly higher in VD. In moderate dementia groups, the frequency of graphic difficulties was significantly higher in VD and the difference in the frequency of spatial and/or planning deficit seen in mild dementia disappeared. The present study suggests that qualitative analyses of clock drawings could demonstrate the neuropsychological profiles of AD and VD and their differences between these dementias.
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Affiliation(s)
- Y Kitabayashi
- Department of Psychiatry, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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Abstract
OBJECTIVE To test the hypothesis that performance on a clock-drawing test in a mailed survey to an older cohort is associated with known and potential risk and protective factors for Alzheimer's disease. DESIGN The Leisure World Cohort Study is an ongoing study, begun in 1981, of nearly 14,000 older adults. In November 1992, the 8,406 living cohort members were mailed a follow-up questionnaire. SETTING Leisure World Laguna Hills, a southern California retirement community. PARTICIPANTS The study population is a predominantly white, well-educated, upper-middle-class community; approximately two-thirds are women. Data from 4,843 cohort members (mean age 80 years; range 52-101) were analyzed. MEASUREMENTS The questionnaire included a clock-drawing task: a predrawn circle 3 1/4 inches (8.3 cm) in diameter was provided with instructions "In the circle below, draw in the numbers as on a clock face. Make no erasures." Clocks were scored on 7 items: all numbers 1-12 present without adding extra or omitting numbers, sequencing of numbers, position of numbers, orientation of numbers to circle, consistent number style (either Arabic or Roman), tilt of numbers, and superfluous marks. A total clock score was calculated by summing the number of correct individual items (0-7). We also classified individuals as cognitively impaired by a previously suggested method: individuals were affected if they did not have three numbers drawn in the upper left quadrant of the clock face. RESULTS Ninety percent or more of the participants across all ages placed the numbers 1 to 12 on their clocks without omissions or additions; 35% completed the clock drawing without error. The mean total clock scores decreased with each successive 5-year age group in both men and women. Regression analysis indicated a significant effect for age (b = -0.15, P <.0001), education (b = 0.05, P =.0001), smoking (b = 0.13, P =.03), and female gender (b = -0.05, P =.05) and a marginally significant effect of nonrheumatoid arthritis (b = 0.05, P =.07) on total clock score. No other measured variable had a significant effect. Cognitively impaired individuals were more likely to be female and older. After adjusting for age and gender, they were also more likely to be hypertensive and to have taken blood pressure medication and less likely to be college graduates, have glaucoma or arthritis, and to have taken vitamin supplements. CONCLUSION The clock-drawing task is an appealing measure of cognitive function for large epidemiological studies because it is a simple, self-administered test that is easily adapted to mail surveys and correlates with more-detailed and more-time-consuming cognitive screens. Although it is relatively free of influence by language, cultural, or ethnic factors, our study shows that even in a highly educated population, clock drawing is influenced by educational level and other known risk factors for Alzheimer's disease. Thus a clock-drawing task may help predict cognitive frailty and future disability in older people. Such determination can direct high-risk individuals to earlier diagnosis, potential therapies, and better management.
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Affiliation(s)
- A Paganini-Hill
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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49
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Abstract
BACKGROUND As elderly populations grow, dementia detection in the community is increasingly needed. Existing screens are largely unused because of time and training requirements. We developed the Mini-Cog, a brief dementia screen with high sensitivity, specificity, and acceptability. Here we describe the development of its scoring algorithm, its receiver operating characteristics (ROC), and the generalizability of its clock drawing scoring system. SAMPLE AND METHODS A total of 249 multi-lingual older adults were examined. Scores on the three-item recall task and the clock drawing task (CDT-CERAD version) were combined to create an optimal algorithm. Receiver operating characteristics for seven alternatives were compared with those of the MMSE and the CASI using expert raters. To assess the CDT scoring generalizability, 20 naïve raters, without explicit instructions or prior CDT exposure, scored 80 randomly selected clocks as "normal" or "abnormal" (20 from each of four CERAD categories). RESULTS An algorithm maximizing sensitivity and correct diagnosis was defined. Its ROC compared favorably with those of the MMSE and CASI. CDT concordance between naïve and trained raters was >98% for normal, moderately and severely impaired clocks, but lower (60%) for mildly impaired clocks. Recalculation of the Mini-Cog's performance, assuming that naïve raters would score all mildly impaired CDTs in the full sample as normal, retained high sensitivity (97%) and specificity (95%). CONCLUSION The Mini-Cog algorithm performs well with simple clock scoring techniques. The results suggest that the Mini-Cog may be used successfully by relatively untrained raters as a first-stage dementia screen. Further research is needed to characterize the Mini-Cog's utility when population dementia prevalences are low.
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Affiliation(s)
- J Scanlan
- Alzheimer's Disease Research Center, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195-6560, USA.
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50
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Abstract
OBJECTIVE The clock-drawing test has achieved widespread clinical use in recent years as a cognitive screening instrument and a significant amount of literature relates to its psychometric properties and clinical utility. This review aims to synthesize the available evidence and assess the value of this screening test according to well-defined criteria. DESIGN A Medline and Psycho-info literature search of all languages was done from 1983 to 1998 including manual cross-referencing of bibliographies. A brief summary of all original scoring systems is provided as well as a review of replication studies. Psychometric data including correlations with other cognitive tests were recorded. Qualitative aspects of the test are also described. RESULTS Among published studies, the mean sensitivity (85%) and specificity (85%) of the clock-drawing test are impressive. Correlations with the Mini-Mental State Examination and other cognitive tests was high, generally greater than r = 0.5. High levels of inter-rater and test-re-test reliability and positive predictive value are recorded and despite significant variability in the scoring systems, all report similar psychometric properties. The clock test also shows a sensitivity to cognitive change with good predictive validity. CONCLUSIONS The clock-drawing test meets defined criteria for a cognitive screening instrument. It taps into a wide range of cognitive abilities including executive functions, is quick and easy to administer and score with excellent acceptability by subjects. Together with informant reports, the clock-drawing test is complementary to the widely used and validated Mini-Mental State Examination and should provide a significant advance in the early detection of dementia and in monitoring cognitive change. A simple scoring system with emphasis on the qualitative aspects of clock-drawing should maximize its utility.
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Affiliation(s)
- K I Shulman
- Department of Psychiatry, University of Toronto, Sunnybrook & Women's College Health Sciences Centre, Ontario, Canada.
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