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Can clock drawing differentiate Alzheimer's disease from other dementias?

Published online by Cambridge University Press:  03 July 2015

Lynnette Pei Lin Tan ,
Nathan Herrmann ,
Brian J. Mainland  and
Kenneth Shulman
Lynnette Pei Lin Tan*
Affiliation:
Department of Psychiatry, Sunnybrook Health Sciences Centre, Canada; Department of Psychological Medicine, Tan Tock Seng Hospital, Singapore
Nathan Herrmann
Affiliation:
Division of Geriatric Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre, Canada; Department of Psychiatry, University of Toronto, Canada
Brian J. Mainland
Affiliation:
Department of Psychology, Ryerson University, Toronto, Canada
Kenneth Shulman
Affiliation:
Sunnybrook Health Sciences Centre, Canada; Department of Psychiatry, University of Toronto, Canada
*
Correspondence should be addressed to: Lynnette Pei Lin Tan, Psychological Medicine Department, Tan Tock Seng Hospital, Annex Building Level 3, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. Phone: +65 63577841; Fax: +65 63573088. Email: lynnette_tan@ttsh.com.sg.
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Abstract

Background:

Studies have shown the clock-drawing test (CDT) to be a useful screening test that differentiates between normal, elderly populations, and those diagnosed with dementia. However, the results of studies which have looked at the utility of the CDT to help differentiate Alzheimer's disease (AD) from other dementias have been conflicting. The purpose of this study was to explore the utility of the CDT in discriminating between patients with AD and other types of dementia.

Methods:

A review was conducted using MEDLINE, PsycINFO, and Embase. Search terms included clock drawing or CLOX and dementia or Parkinson's Disease or AD or dementia with Lewy bodies (DLB) or vascular dementia (VaD).

Results:

Twenty studies were included. In most of the studies, no significant differences were found in quantitative CDT scores between AD and VaD, DLB, and Parkinson's disease dementia (PDD) patients. However, frontotemporal dementia (FTD) patients consistently scored higher on the CDT than AD patients. Qualitative analyses of errors differentiated AD from other types of dementia.

Conclusions:

Overall, the CDT score may be useful in distinguishing between AD and FTD patients, but shows limited value in differentiating between AD and VaD, DLB, and PDD. Qualitative analysis of the type of CDT errors may be a useful adjunct in the differential diagnosis of the types of dementias.

Keywords

clock-drawing testAlzheimer’s diseasevascular dementiaParkinson’s dementiadementia with Lewy bodiesfrontotemporal dementia

Information

Type
Review Article
Information
International Psychogeriatrics , Volume 27 , Special Issue 10: Psychosocial and Ethical Aspects of Dementia , October 2015 , pp. 1649 - 1660
Copyright
Copyright © International Psychogeriatric Association 2015 

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References

Albert, M. S. and Kaplan, E. (1980). Organic Implications of Neuropsychological Deficits in the Elderly, New Directions in Memory and Aging. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.Google Scholar
Barr, A., Benedict, R., Tune, L. and Brandt, J. (1992). Neuropsychological differentiation of Alzheimer's disease from vascular dementia. International Journal of Geriatric Psychiatry, 7, 621–627.CrossRefGoogle Scholar
Blair, M., Kertesz, A., McMonagle, P., Davidson, W. and Bodi, N. (2006). Quantitative and qualitative analyses of clock drawing in frontotemporal dementia and Alzheimer's disease. Journal of the International Neuropsychological Society, 12, 159–165.CrossRefGoogle ScholarPubMed
Brodaty, H. and Moore, C. M. (1997). The clock drawing test for dementia of the Alzheimer's type: a comparison of three scoring methods in a memory disorders clinic. International Journal of Geriatric Psychiatry, 12, 619–627.3.0.CO;2-H>CrossRefGoogle Scholar
Cagnin, A.et al. (2013). Clinical and cognitive correlates of visual hallucinations in dementia with Lewy bodies. Journal of Neurology Neurosurgery & Psychiatry, 84, 505–510.CrossRefGoogle ScholarPubMed
Cahn-Weiner, D. A., Williams, K., Grace, J., Tremont, G., Westervelt, H. and Stern, R. A. (2003). Discrimination of dementia with lewy bodies from Alzheimer disease and Parkinson disease using the clock drawing test. Cognitive and Behavioral Neurology, 16, 85–92.CrossRefGoogle ScholarPubMed
Calderon, J., Perry, R. J., Erzinclioglu, S. W., Berrios, G. E., Dening, T. R. and Hodges, J. R. (2001). Perception, attention, and working memory are disproportionately impaired in dementia with Lewy bodies compared with Alzheimer's disease. Journal of Neurology Neurosurgery & Psychiatry, 70, 157–164.CrossRefGoogle ScholarPubMed
Chui, H. C., Victoroff, J. I., Margolin, D., Jagust, W., Shankle, R. and Katzman, R. (1992). Criteria for the diagnosis of ischemic vascular dementia proposed by the State of California Alzheimer's disease diagnostic and treatment Centers. Neurology, 42, 473–480.CrossRefGoogle ScholarPubMed
Clinical and neuropathological criteria for frontotemporal dementia. The Lund and Manchester Groups (1994). Journal of Neurology, Neurosurgery & Psychiatry, 57, 416–418.CrossRefGoogle Scholar
Cosentino, S., Jefferson, A., Chute, D. L., Kaplan, E. and Libon, D. J. (2004). Clock drawing errors in dementia: neuropsychological and neuroanatomical considerations. Cognitive and Behavioral Neurology, 17, 74–84.CrossRefGoogle ScholarPubMed
Diagnostic and statistical manual of mental disorders (3rd edn, revised.) (1987). Washington, DC: American Psychiatric Association.Google Scholar
Diagnostic and statistical manual of mental disorders (4th edn, text rev.) (2000). Washington, DC: American Psychiatric Association.Google Scholar
Eknoyan, D., Hurley, R. A. and Taber, K. H. (2012). The clock drawing task: common errors and functional neuroanatomy. The Journal of Neuropsychiatry & Clinical Neurosciences, 24, 260–265.CrossRefGoogle ScholarPubMed
Emre, M.et al. (2007). Clinical diagnostic criteria for dementia associated with Parkinson's disease. Movement Disorders, 22, 1689–1707.CrossRefGoogle ScholarPubMed
Ferman, T. J.et al. (2006). Neuropsychological differentiation of dementia with Lewy bodies from normal aging and Alzheimer's disease. The Clinical Neuropsychologist, 20, 623–636.CrossRefGoogle ScholarPubMed
Forstl, H., Besthorn, C., Hentschel, F., Geiger-Kabisch, C., Sattel, H. and Schreiter-Gasser, U. (1996). Frontal lobe degeneration and Alzheimer's disease: a controlled study on clinical findings, volumetric brain changes and quantitative electroencephalography data. Dementia, 7, 27–34.Google Scholar
Freedman, M., Leach, L., Kaplan, E., Wnocur, E., Shulman, K. I. and Delis, D. C. (1994). Clock drawing. A Neuropsychological Analysis. Oxford: Oxford University Press.Google Scholar
Gregory, C. A. and Hodges, J. R. (1996). Clinical features of frontal lobe dementia in comparison to Alzheimer's disease. Journal of Neural Transmission Supplementa, 47, 103–123.CrossRefGoogle ScholarPubMed
Hamilton, J. M.et al. (2008). Visuospatial deficits predict rate of cognitive decline in autopsy-verified dementia with Lewy bodies. Neuropsychology, 22, 729–737.CrossRefGoogle ScholarPubMed
Heinik, J., Solomesh, I., Raikher, B. and Lin, R. (2002). Can clock drawing test help to differentiate between dementia of the Alzheimer's type and vascular dementia? A preliminary study. International Journal of Geriatric Psychiatry, 17, 699–703.CrossRefGoogle ScholarPubMed
Kitabayashi, Y., Ueda, H., Narumoto, J., Nakamura, K., Kita, H. and Fukui, K. (2001). Qualitative analyses of clock drawings in Alzheimer's disease and vascular dementia. Psychiatry and Clinical Neurosciences, 55, 485–491.CrossRefGoogle ScholarPubMed
Kozora, E. and Cullum, C. M. (1994). Qualitative features of clock drawings in normal aging and Alzheimer's disease. Assessment, 1, 179–188.CrossRefGoogle ScholarPubMed
Lambon Ralph, M. A., Powell, J., Howard, D., Whitworth, A. B., Garrard, P. and Hodges, J. R. (2001). Semantic memory is impaired in both dementia with Lewy bodies and dementia of Alzheimer's type: a comparative neuropsychological study and literature review. Journal of Neurology Neurosurgery and Psychiatry, 70, 149–156.CrossRefGoogle ScholarPubMed
Lee, A. Y., Kim, J. S., Choi, B. H. and Sohn, E. H. (2009). Characteristics of clock drawing test (CDT) errors by the dementia type: quantitative and qualitative analyses. Archives of Gerontology and Geriatrics, 48, 58–60.CrossRefGoogle ScholarPubMed
Lee, J. H., Oh, E. S., Jeong, S. H., Sohn, E. H., Lee, T. Y. and Lee, A. Y. (2011). Longitudinal changes in clock drawing test (CDT) performance according to dementia subtypes and severity Archives of Gerontology and Geriatrics, 53, e179–e182.CrossRefGoogle ScholarPubMed
Libon, D. J., Malamut, B. L., Swenson, R., Sands, L. P. and Cloud, B. S. (1996). Further analyses of clock drawings among demented and nondemented older subjects. Archives of Clinical Neuropsychology, 11, 193–205.CrossRefGoogle ScholarPubMed
Libon, D. J., Swenson, R. A., Barnoski, E. J. and Sands, L. P. (1993). Clock drawing as an assessment tool for dementia. Archives of Clinical Neuropsychology, 8, 405–415.CrossRefGoogle ScholarPubMed
Looi, J. C. and Sachdev, P. S. (1999). Differentiation of vascular dementia from AD on neuropsychological tests. Neurology, 53, 670–678.CrossRefGoogle ScholarPubMed
Mainland, B. J., Amodeo, S. and Shulman, K. I. (2014). Multiple clock drawing scoring systems: simpler is better. International Journal of Geriatric Psychiatry, 29, 127–136.CrossRefGoogle ScholarPubMed
Manos, P. J. and Wu, R. (1994). The ten point clock test: a quick screen and grading method for cognitive impairment in medical and surgical patients. The International Journal of Psychiatry in Medicine, 24, 229–244.CrossRefGoogle ScholarPubMed
Matioli, M. N. and Caramelli, P. (2010). Limitations in differentiating vascular dementia from Alzheimer's disease with brief cognitive tests. Arquivos de Neuro-psiquiatria, 68, 185–188.CrossRefGoogle ScholarPubMed
McGuinness, B., Barrett, S. L., Craig, D., Lawson, J. and Passmore, A. P. (2010). Executive functioning in Alzheimer's disease and vascular dementia. International Journal of Geriatric Psychiatry, 25, 562–568.CrossRefGoogle ScholarPubMed
McKeith, I. G.et al. (1996). Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): report of the consortium on DLB international workshop. Neurology, 47, 1113–1124.CrossRefGoogle Scholar
McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D. and Stadlan, E. M. (1984). Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology, 34, 939–944.CrossRefGoogle ScholarPubMed
Mendez, M. F., Ala, T. and 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.CrossRefGoogle ScholarPubMed
Mondini, S., Mapelli, D., Vestri, A. and Bisiacchi, P. S. (2003). Esame NeuropsicoLogico Breve: Una Batteria Di Test Per Lo Screening NeuropsicoLogico. Milano, Italia: Cortina.Google Scholar
Moretti, R., Torre, P., Antonello, R. M., Cazzato, G. and Bava, A. (2002). Ten-point clock test: a correlation analysis with other neuropsychological tests in dementia. International Journal of Geriatric Psychiatry, 17, 347–353.CrossRefGoogle ScholarPubMed
Morris, J. C.et al. (1989). The consortium to establish a registry for Alzheimer's disease (CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer's disease. Neurology, 39, 1159–1165.Google Scholar
Neary, D.et al. (1998). Frontotemporal lobar degeneration: a consensus on clinical diagnostic criteria. Neurology, 51, 1546–1554.CrossRefGoogle ScholarPubMed
O’Brien, T. J., Wadley, V., Nicholas, A. P., Stover, N. P., Watts, R. and Griffith, H. R. (2009). The contribution of executive control on verbal-learning impairment in patients with Parkinson's disease with dementia and Alzheimer's disease. Archives of Clinical Neuropsychology, 24, 237–244.CrossRefGoogle ScholarPubMed
Palmqvist, S., Hansson, O., Minthon, L. and Londos, E. (2009). Practical suggestions on how to differentiate dementia with Lewy bodies from Alzheimer's disease with common cognitive tests. International Journal of Geriatric Psychiatry, 24, 1405–1412.CrossRefGoogle ScholarPubMed
Perri, R.et al. (2005). Alzheimer's disease and frontal variant of frontotemporal dementia– a very brief battery for cognitive and behavioural distinction. Journal of Neurology, 252, 1238–1244.CrossRefGoogle ScholarPubMed
Pinto, E. and Peters, R. (2009). Literature review of the clock drawing test as a tool for cognitive screening. Dementia and Geriatric Cognitive Disorders, 27, 201–213.CrossRefGoogle ScholarPubMed
Rascovsky, K.et al. (2002). Cognitive profiles differ in autopsy-confirmed frontotemporal dementia and AD. Neurology, 58, 1801–1808.CrossRefGoogle ScholarPubMed
Roh, J. H. and Lee, J. H. (2014). Recent updates on subcortical ischemic vascular dementia. Journal of Stroke, 16, 18–26.CrossRefGoogle ScholarPubMed
Roman, G. C.et al. (1993). Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN International Workshop. Neurology, 43, 250–260.CrossRefGoogle ScholarPubMed
Rouleau, I., Salmon, D. P., Butters, N., Kennedy, C. and McGuire, K. (1992). Quantitative and qualitative analyses of clock drawings in Alzheimer's and Huntington's disease. Brain and Cognition, 18, 70–87.CrossRefGoogle ScholarPubMed
Royall, D. R., Cordes, J. A. and Polk, M. (1998). CLOX: an executive clock drawing task. Journal of Neurology Neurosurgery Psychiatry, 64, 588–594.CrossRefGoogle ScholarPubMed
Saka, E. and Elibol, B. (2009). Enhanced cued recall and clock drawing test performances differ in Parkinson's and Alzheimer's disease-related cognitive dysfunction. Parkinsonism & Related Disorders, 15, 688–691.CrossRefGoogle ScholarPubMed
Sallam, K. and Amr, M. (2013). The use of the mini-mental state examination and the clock-drawing test for dementia in a tertiary hospital. Journal of Clinical Diagnostic Research, 7, 484–488.Google ScholarPubMed
Salmon, D. P. and Bondi, M. W. (2009). Neuropsychological assessment of dementia. Annual Review of Psychology, 60, 257–282.CrossRefGoogle ScholarPubMed
Salmon, D. P. and Butters, N. (1992). Neuropsychological assessment of dementia in elderly. In Katzman, R., Rowe, J. (eds.), Principles of Geriatric Neurology (pp. 144–163). Philadelphia: Davis.Google Scholar
Shulman, K. I. (2000). Clock-drawing: is it the ideal cognitive screening test?. International Journal of Geriatric Psychiatry, 15, 548–561.3.0.CO;2-U>CrossRefGoogle ScholarPubMed
Shulman, K. I., Pushkar Gold, D., Cohen, C. A. and Zucchero, C. A. (1993). Clock-drawing and dementia in the community: a longitudinal study. International Journal of Geriatric Psychiatry, 8, 487–496.CrossRefGoogle Scholar
Strauss, E., Sherman, E. M. S. and Spreen, O. (2006). A Compendium of Neuropsychological Tests. Oxford: Oxford University Press.Google Scholar
Sunderland, T.et al. (1989). Clock drawing in Alzheimer's disease. A novel measure of dementia severity. Journal of the American Geriatric Society, 37, 725–729.CrossRefGoogle ScholarPubMed
Watson, Y. I., Arfken, C. L. and Birge, S. J. (1993). Clock completion: an objective screening test for dementia. Journal of the American Geriatric Society, 41, 1235–1240.CrossRefGoogle ScholarPubMed
Wiechmann, A. R., Hall, J. R. and O’Bryant, S. (2010). The four-point scoring system for the clock drawing test does not differentiate between Alzheimer's disease and vascular dementia. Psychological Reports, 106, 941–948.CrossRefGoogle Scholar
Wolf-Klein, G. P., Silverstone, F. A., Levy, A. P. and Brod, M. S. (1989). Screening for Alzheimer's disease by clock drawing. Journal of the American Geriatric Society, 37, 730–734.CrossRefGoogle ScholarPubMed
You, J. S., Chen, R. Z., Zhang, F. M., Zhou, Z. Y., Cai, Y. F. and Li, G. F. (2011). The chinese (cantonese) montreal cognitive assessment in patients with subcortical ischemic vascular dementia. Dementia and Geriatric Cognitive Disorders Extra, 1, 276–282.CrossRefGoogle ScholarPubMed