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Clock Drawing Test (CDT)

The Clock Drawing Test (CDT) is a simple, quick, and easy-to-administer screening test used
both in clinical practice and in research to assess the cognitive status of the subject. It evaluates different
mechanisms involved in task execution, primarily visoperceptive, visomotor functions and
visuoconstructive, planning and motor execution.

The Clock Drawing Test (TDR) is a test originally developed by Battersby, Bender, Pollack, and Kahn in
1956 to detect contralateral neglect in patients with parietal lobe injury. Currently, its application
it has been extended as the TDR is a test that provides valuable information about various cognitive areas
activated in the execution of this brief test that correspond to cognitive functions similar to those evaluated by the
Mini-Mental State Examination by Folstein, including language, short-term memory, executive functions, praxis and
spatial visions.

Various authors, based on the results obtained from the conducted research, propose the use of
TDR as an effective tool in the detection of cognitive decline in patients with Alzheimer's Type Dementia.
This test is highly sensitive and specific, perfectly distinguishing between subjects with a diagnosis of Dementia.
Probable Alzheimer's type (DAT) and subjects without such pathology. The execution in the TDR of patients affected by DAT is
worse, they score lower than subjects not affected by this dementing process regardless of the scale of
calibration that is used in its correction.

The fact that TDR has been applied from different fields of clinical practice and neuropsychological research.
It is probably due to the fact that, although seemingly simple, the task of correctly drawing a clock requires the
coordinated participation of numerous and different cognitive aspects that are not necessary to create other drawings
simpler, such as a house or a tree. The errors we observe in their execution certainly reflect
certain deficiencies attributable to specific neurological alterations or injuries; that is, the type of errors that
A patient committing during the test may vary depending on the pathology they suffer from, as well as the location and
extent of their neurological injuries.

When a patient is asked to draw a clock, they will be able to do so if they retain certain abilities. For
For example, a patient who must write all the numbers and simultaneously arrange them correctly in space.
you will need to make appropriate planning to coordinate this task; you will also need to have visual organization and
motor, as well as the ability to simultaneously process the task it is executing. If said task includes among its
instructions that the clock indicates a certain time pattern, will have to store in memory and
subsequently recover that information, to correctly locate the hands. All these language processes,
memory, visuospatial coordination, involve the participation of cortical and subcortical brain areas, anterior
and later, as well as the right and left cerebral hemispheres. If a patient has a certain aspect
selectively impaired cognitive, in a thorough analysis of the TR we could observe qualitative differences
regarding a healthy subject. Therefore, for the TR to be considered as a quick assessment test of the
cognitive deterioration it would be relevant to establish some criteria according to which to carry out a quantitative analysis and
appropriate qualitative.

If a patient, for example, is unable to draw a clock face large enough to place in it.
all the numbers, this micrograph could be a marker of alteration in the basal ganglia. On the other hand, they could
analyze aspects such as: evaluating the correct placement of numbers, positioning numbers first
reference as 3, 6, 9, and 12; observe if the numbers are correctly ordered and if they are all present in both
the left hemifield as in the right, suggesting otherwise an alteration of the visuospatial attention hemifield
from the contralateral hemisphere.

In the last decade, there has been a certain rise in the application of TDR for the study and assessment of the
neurodegenerative diseases, especially for dementia and Alzheimer's disease. At the same time, it
they have been developing various methods to apply and score the TDR. However, a certain criteria has not yet been established.
standardized criteria for its application and scoring.

Scoring criteria

J. Cacho and colleagues (1998) have proposed scoring scales based on the criteria of the previously established scale.
used by Rouleau et al (1992), although with various modifications, which have essentially consisted of introducing
the qualitative parameters reverse rotation, numerical alignment, and perseveration within the scoring scale.
According to these criteria, a maximum score of 2 points has been established for the drawing of the sphere, 4 points for the
numbers and 4 points for the hands.
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Scoring criteria for the clock test (J. Cacho et al.)

Clock face (maximum 2 points).
Drawing norm. Circular or oval sphere with small distortions due to shaking.
2 Points.
Incomplete or with significant distortion. Very asymmetric sphere.
1 Point.
Absence or totally distorted drawing.
0 Points.

2. Presence or sequence of the numbers (maximum 4 points).

All the numbers present and in the correct order. Just 'small errors' in the spatial localization in
4 Points. less than 4 numbers (e.g. place the number 8 in the space of the number 9).
When the 'small errors' in spatial placement occur in 4 or more small numbers.
3.5
Points.
Everyone present with a significant error in spatial localization (e.g. placing the number 3 in the space
3 Points. of number 6).
Numbers with some disorder of sequence (less than 4 numbers).
Omission or addition of a number, but without major distortions in the remaining numbers.
2 Points. Numbers with some disorder in sequence (4 or more numbers).
The 12 numbers placed counterclockwise (reverse rotation).
All the numbers present, but with great spatial distortion (numbers outside the clock or drawn in
media sphere, etc...)
Presence of the 12 numbers in a vertical, horizontal, or diagonal line (numerical alignment).
Absence or excess of numbers with great spatial distortion.
1 Point. Numeric alignment with lack or excess of numbers.
Inverse rotation with lack or excess of numbers.
Absence or scarce representation of numbers (fewer than 6 numbers drawn).
0 Points.

3. Presence and location of the hands (maximum 4 points).

The hands are in the correct position and with the appropriate size proportions (the hour hand is longer)
4 Points. cut).
The hands in the correct position but both of equal size.
3.5
Points.
Small errors in the positioning of the hands (placing one of the hands in the space intended for
3 Points. previous or subsequent number.
Minute hand shorter than the hour hand, with correct hour markings.

2 Points. Great distortion in the positioning of the hands (even if they point to eleven and ten, when the numbers
they present significant errors in spatial localization).

When the hands do not meet at the central point and mark the correct time.
When the hands do not meet at the central point and indicate an incorrect hour.
1 Point.
Presence of a single hand or a sketch of both.

Absence of hands or perseverance in the drawing of them. Effect in the shape of a "wagon wheel."
0 Points.
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Application criteria

It must be applied in two successive phases, following the established order:

1. Clock test on command (TRO). In this phase, the subject is presented with a completely blank sheet of paper,
a pencil and an eraser, and you are given the following instructions: 'I would like you to draw a clock'
round and large on this sheet, placing all its numbers in it and with its hands pointing to eleven and ten. In case
If you make any mistakes, here is an eraser so you can correct it. This test has no time limit.
so we ask you to do it calmly, paying all the attention that is possible to you.

Repeat the instructions as many times as necessary. If the subject, after drawing the sphere, omits any
number, he is asked if he has put them all, allowing him to correct the drawing if he becomes aware of his mistakes. If, by
On the contrary, they do not perceive the error, either because a number is missing or there is an excess, they are reminded of the instruction of the guideline.
schedule.

Once the numbers are drawn, you are reminded to position the hands marking eleven and ten. If elapsed
at one time, the subject has not drawn the hands or is missing one of them, they are asked if they have finished their clock. In case
affirmative, you are informed that, subsequently, they are going to develop an easier test, starting then with the
completion of the TR phase 'to the copy'. Otherwise, an additional period of time is granted to complete the
task.

2. Clock test for the copy (TRC). In this second condition, the subject is presented with a sheet in a vertical position, with
a clock printed in the upper third of the page.

You are asked to pay maximum attention to the drawing and copy the clock drawing that appears as accurately as possible.
at the top of the page. Since no time limit is set in this phase either, it is suggested that you complete it.
calmly and that he uses the eraser in case he makes any mistakes.

At the end of this test, the sheet will be removed for later evaluation and scoring. If the clock is incomplete, before
pick up the sheet he is asked if the drawing is finished. If the subject notices the existence of any error, he is allowed to
rectify it, otherwise the sheet will be collected.

Cut-off points for the estimation of cognitive impairment associated with Alzheimer's type dementia

In the TRO condition, the cutoff point that shows the highest effectiveness is 6. Therefore, the test is considered as
positive if the value of the sum of the three scores (sphere, numbers, and hands) 'in order' is less than or equal to 6, and
as negative if the sum of the scores is greater than 6. High scores are used to discard the
disease, especially scores close to 8 and 9.

In the TRC condition, the point of greatest effectiveness is 8. Therefore, the test is considered positive if the value of the
the sum of the three scores (sphere, numbers, and hands) 'in the copy' is less than or equal to 8, and as negative if the
the sum of the scores is greater than 8.

The most effective cutoff point for TRO+ TRC is 15. Thus, the test is considered positive if the value of the
the sum of the three scores (sphere, numbers, and hands) in the two conditions of the test (order and copy) is less than or
equal to 15, and as negative if the sum of the scores is greater than 15.

The appearance of reverse rotation or numerical alignment, as well as the perseveration of errors in either of the two.
Experimental conditions (TRO and TRC) may indicate a probable cognitive decline.