CLOCK DESIGN TEST
Objectives :
Introduction
Purpose
Procedure
Scoring
Interpretation
Strengths
Limitations
Report writing
Introduction
• It is a cognitive screening test.
• Clock Drawing Test (CDT) was introduced in 1946 by psychiatrist Lawrence
S. Halstead as part of his Halstead-Reitan Neuropsychological Battery.
• Initially designed to assess perceptual and motor skills, CDT evolved into a
cognitive screening tool.
• Developed by Brodaty and Moore in 1997 as a screening tool for cognitive
impairment. Adapted from the original concept introduced by Shulman et al. in
1993
• The CDT gained popularity in the 1980s and 1990s as a quick and inexpensive
cognitive assessment tool for various populations.
Purpose
• After the MMSE, clock drawing test (CDT) is the second most widely used
test for grading cognitive states.
• Applied from age 8 an onwards.
• Can be incorporated into routine screenings for older adults.
• Screens for cognitive decline, aiding early detection of Dementia and
Alzheimer's disease.
• Assesses cognitive impairment in neurological disorders including delirium,
focal cerebral lesions, schizophrenia, Huntington's disease and constructional
apraxia etc.
• Supports research and guides clinical diagnosis.
Parameters assessed
• Executive Function
• Visuospatial Abilities
• Attention and Concentration
• Memory Function
• Motor Skills
• Cognitive Flexibility
• Overall Cognitive Function
Procedure
• Only requires a pencil and a piece of paper with a pre-drawn circle of approximately 10 cm in
diameter.
• The participant is asked to draw the numbers on the clock face.
• Then, they are instructed to draw the hands to indicate a specific time.
• Commonly chosen time is 10 minutes after 11.
• One variation involves providing a blank piece of paper. Participants are asked to draw a clock
showing 10 minutes after [Link] word "hands" is not used to avoid providing clues.
• There is no time limit for the Clock Drawing Test (CDT) but it typically ranges from 3 to 5
minutes per drawing task, varying based on professional discretion and assessment
protocols.
Instructions
1. Use pre-drawn circle
2. “Please draw the numbers of the clock.” Allow them to complete.
3. “Please set the time at ten minutes after eleven.”
Types of Scoring
There are as many as 15 different ways to score the clock-drawing test.
• Simple Scoring: Assigns one point for a correct drawing and zero points for
incorrect or incomplete drawings.
• Complex Scoring: Evaluates various components separately, such as
placement of numbers and correctness of clock hands. Offers a nuanced
assessment of cognitive function.
• Error-based Scoring: Considers specific errors like missing numbers or
incorrect sequence, deducting points accordingly. Provides insight into
cognitive deficits.
• Combined Scoring: Integrates elements of simple, complex, and error-based
methods. Balances overall accuracy with consideration of specific errors.
• Standardized Scoring Systems: Utilizes detailed criteria for scoring, ensuring
consistency and reliability. Incorporates multiple aspects of the drawing for
comprehensive evaluation.
Scoring : Manos and Wu method
Quantitative type scoring
• Clock divided into eighths starting from 12.
• Use a straight edge or template for accuracy.
• One point each is given for the numbers 1, 2, 4, 5, 7, 8, 10, and 11 if
at least half the area of the number is in the proper octant of the circle
relative to the number 12.
• One point each is given for an obvious short hand pointing at the 11
and an obvious long hand pointing to the 2.
• Difference in hand lengths must be obvious.
Interpretation
• A score of 10 suggests that cognitive impairment (CI) is unlikely
• However, a score of less than eight indicates almost CI,
• And a score of less than five indicates prominent impairment.
• In medically stable patients, scores remain stable from one day to the next.
Sunderland et al. method of scoring
Semi-quantitative type scoring.
10-6 Drawing of clock face with circle and numbers is generally
intact.
• 10: Hands are in correct position.
• 9 :Slight errors in placement of hands.
• 8: More noticeable errors in placement of hour and minute hands.
• 7 :Placement of hands is significantly off course.
• 6 :Inappropriate use of clock hands (i.e., use of digital display or circling
of numbers despite repeated instructions).
5-1 Drawing of a clock face with circle and numbers is not intact.
• 5 :Crowding of numbers at one end of the clock or reversal of numbers.
Hands may still be present in some fashion.
• 4 :Further distortion of number sequence. Integrity of clock face is now
gone (i.e., numbers missing or placed at outside of the boundaries of the
clock face).
• 3: Numbers and clock face no longer obviously connected in drawing.
Hands are not present.
• 2 :Drawing reveals some evidence of instructions being received but only a
vague representation of a clock.
• 1 :Either no attempt or an uninterpretable effort is made
Interpretation
• Cut off score: 5 or less indicate impairment
• Higher scores suggest better cognitive function and performance. Lower scores
may indicate cognitive impairment or deficits in specific cognitive domains.
DIFFERENCE BETWEEEN
SCORING METHODS
Sunderland Method Manos and Wu method
• Evaluates various cognitive domains including • Primarily assesses spatial and constructional abilities.
executive functioning, memory, and visuospatial • Scores aspects such as the presence of numbers in the
abilities. correct sequence, placement of hands indicating
• Considers the presence and accuracy of numbers, specified time, symmetry, and overall organization.
the placement and symmetry of the clock face, • Focuses more on the spatial and organizational
the positioning of clock hands, and additional aspects of the drawing.
elements like clock face orientation. • Emphasizes correct placement and organization of
• Provides a comprehensive assessment of elements within the drawing.
cognitive function beyond spatial abilities.
• Emphasizes the broader cognitive implications of
the drawing.
Critical Test Errors
• Errors identified in dementia: These were described as critical clock drawing
errors and included the wrong time, no hands, missing numbers, number
substitutions, repetition, and refusal.
• Common errors in Alzheimer's disease include : Perseveration, counter-
clockwise numbering, absence of numbers and irrelevant spatial arrangement.
• Errors following stroke may reflect : spatial neglect, hemianopsia and
sensory loss, in addition to errors suggestive of cognitive dysfunction
(Freidman 1991).
Strengths
• CDT is non verbal test of cognition.
• Budget friendly
• Quick screening tool
• Sensitive to cognitive impairment, aiding in diagnosis.
• Used for research purposes
• Widely used across multiethnic populations and neurological
conditions.
Limitations
• Lack of Specificity: Doesn't differentiate between types of cognitive impairment.
• Dependence on visual-spatial skills of the participant.
• Scoring criteria inconsistency among clinicians.
• Accuracy affected by motivation and attention of participant.
• Limited diagnostic utility and used as a part of battery test.
• Cultural and Educational Bias: Performance influenced by background and education
level.
Report writing
[Link]:
Provide background information (Demographics) on the patient and reason
for conducting the Clock Drawing Test (CDT) including presenting
complaints.
[Link] History:
Summarize relevant medical history, including past diagnoses, medications,
and cognitive symptoms.
[Link] Administration:
Describe how the CDT was administered, including instructions given to the
patient and any variations used.
[Link]:
Document observations during the test, such as the patient's approach to the
task, drawing techniques, and errors made.
[Link]:
Apply the chosen scoring method (i.e. Manos and Wu method) to assess the
accuracy and completeness of the clock drawing
[Link]:
Analyze the test results in the context of the patient's overall cognitive
function and compare with expected norms.
[Link] Implications:
Discuss the implications of the CDT findings for the patient's diagnosis,
prognosis, and treatment planning.
[Link]:
Summarize key findings from the CDT and provide recommendations for
further assessment or intervention if necessary.
[Link]:
Cite any relevant literature or guidelines used in the interpretation and
reporting of the CDT results.
THANKYOU
ANY QUESTIONS?
