It takes thinking ability to turn “Draw a clock” into the act itself. Rarely will the task take more than 10 minutes. The Alzheimer's Association also recommends this simple scoring method, concluding that a normal clock (or a score of one point) indicates the absence of dementia, while an abnormally completed clock is cause for further evaluation. The CDT also provides a powerful visual for families to see that something is wrong with their loved one. 47 The patient is then asked to draw the hands on the clock to indicate “ten minutes past 11 o’clock.” He may be able to get dressed, but not be able to determine that he should wear a warm coat out if it is cold outside. Someone whose brain doesn’t correctly process information might draw hands pointing to the 10 and the 11. More on how to assess the Clock-Drawing Test results below. Clock-drawing is a widely used bedside test of constructional ability, but it has never been systematically studied or standardized. Free shipping on many items | Browse your favorite brands | … Read our, Medically reviewed by Diana Apetauerova, MD, Medically reviewed by Nicholas R. Metrus, MD, Medically reviewed by Shaheen Lakhan, MD, PhD, Montreal Cognitive Assessment (MoCA) Test for Dementia, Screening Tests Used for Alzheimer's and Other Dementias, Alzheimer's Blood Test Available For Purchase, But Not Yet FDA-Approved, How the Mini-Cog Is Used to Test for Alzheimer's and Dementia, AD8 Dementia Screening Interview for Caregivers. Placement of the numbers around the circle requires visual-spatial, numerical sequencing, and planning abilities. These researchers concluded that these six errors were predictive in identifying dementia based on the clock-drawing test. Time That Tells: Critical Clock-Drawing Errors for Dementia Screening. It simply involves answering questions about a loved one’s behavior, nothing is required of the individual who may have dementia. It incorporated qualitative features of the clock and consisted of 15 descriptors or “critical items” characteristic of a “good” clock, with one point assigned for presence of each critical item. So, if dementia can be detected in its earlier stages, it can be treated earlier and hopefully extend the amount of time the person functions well. Patients with Parkinson’s disease dementia and Huntington’s disease, a rarer dementia that can develop in a person’s 30s and 40s, are prone to draw a smaller clock (less than two inches), while people with Alzheimer’s disease tend to draw bigger (more than 10 inches) clocks. First, draw a circle and turn it into a clock face, filling in all the numbers. The clock-drawing test picks up fewer than 20 percent of neglect cases, and the simple line-bisection task misses 40 percent of all … Cognitive Testing. Sit your loved one down at the table and provide a single sheet of paper (a blank 8.5-by-11-inches sheet is fine) and a writing utensil. The brain has to be able to know to first draw a circle, then numbers, then the hands. A normal score is four or … The test is administered as follows: 1. The site is for educational purposes, medical decisions should not be based on its content and its authors assume no liability for errors or omissions. Scoring: One point is … Studies are mixed on whether complicated scoring, to determine the severity or stage of dementia, is more effective than simple pass/fail, but the consensus among experts is that the CDT is useful for figuring out if further testing is required, regardless of how it’s scored. Aprahamian I, Martinelli JE, Neri AL, Sanches Yassuda, M. International Psychogeriatrics. Stroke patients with RCP often have lesions involving the right parietal lobe and subcortical area. Return to Top ©1996-2020, S. Plous: Psychology Headlines From Around the World. The CDK can be effectively administered to resistant and non-compliant older persons, (Freund B, 2005) How When it comes to Alzheimer's, the MIND diet has shown promise in reducing risk and promoting brain health. It’s important to remember that no true diagnosis can be made without further tests from a doctor. This is because size awareness is affected differently depending on which illness is present. Aprahamian, I., Martinelli, J.E., Liberalesso Neri, A., Sanches Yassuda, M. Dementia & Neuropsychologia 2009 June;3(2):74-80. Some clinicians also intentionally omit the word "hands" in their directions to avoid giving the test-taker a cue of what needs to be included in the drawing. 1 point for the correct time. The Clock Drawing Test Instructions General Information: Provide the patient with an 8.5 x 11-in. – Spatial knowledge There can be elaborate scoring methods, assigning points based on positioning of numbers and hands, but simple pass/fail scoring has been shown as effective. What is the Alzheimer’s Clock-Drawing Test? For example, your father could perform well on the MMSE, which would show that his memory still is quite intact, his language and calculation skills remain functional, and his orientation remains fairly normal. 1 point for all the numbers being in the correct order. It is important to note that many publications do not include all six qualitative errors. Early detection is helpful because the medications that are currently available to treat Alzheimer’s disease are generally more effective earlier in the disease process. While it is still used to assess the severity of traumatic brain injury (TBI), since the 1980s it has been more often used to gauge whether someone may be developing Alzheimer’s disease or another related dementia. If questions are asked, either refrain from answering or simply say “just do as you think best”. Can a 7-Minute Screening Test Determine If You Have Dementia? Instruction A – directions given all at once: “Draw the face of the clock, put in all the numbers, and set the time to 10 after 11.” Instruction B – break the task into two steps: “I’d like you to draw a large circle and fill it in with numbers like on the face of a clock. 3. The Accuracy of the Clock Drawing Test Compared to That of Standard Screening Tests for Alzheimer's Disease: Results From a Study of Brazilian Elderly With Heterogeneous Educational Backgrounds. 5 Crowding of numbers at one end of the clock or reversal of numbers. The sum of the scores for each quadrant is the total score for the clock. Someone whose illness is caught earlier will manage symptoms better than someone who waits longer to be diagnosed. The clinician (often a doctor, … Note that it’s also OK to pre-draw a 10-inch circle for your loved one, rather than starting with a blank page. We will draw the clock numbers (1 through 12) in the appropriate positions. 1992): The following instructions are given: “I would like you to draw a clock, put in all the numbers, and set the hands for 10 after 11.” Following this condition, the patients should be instructed to … The clock drawing test (CDT) has been proposed as a quick screening test for cognitive dysfunction secondary to dementia, delirium, or a range of neurological and psychiatric illnesses (Cucinotta D, 2004). It concluded that the easiest scoring method provided results that were just as accurate as the more complicated scoring methods. Finally, there’s abstract thinking. Or if they think their left hand is not their own (common for some types of stroke). The respondent is asked to draw a traditional (analogue) clock face with all the numbers in place and the hands pointing to 11:10 or ten minutes past eleven. Lessig, M., Scanlan J., Nazemi, H., and Borson, S. International Psychogeriatrics. They can work to rule out other potentially reversible causes of dementia, such as vitamin B12 deficiency and normal pressure hydrocephalus, as well as determine an accurate diagnosis and treatment plan. The clock-drawing test is a simple tool that is used to screen people for signs of neurological problems, such as Alzheimer’s and other dementias. – Abstract thinking. It simply means you need to make a doctor’s appointment so your loved one can be evaluated by an expert. One test is to have stand to their left and see if they pay attention to you less than when you stand on the right. How to Converse with People with Dementia, "Positive Approach" for Emotional Distress. Next, draw the hands pointing toward the time 3:20. 1 point for the numbers being in the proper special order. b. needs further evaluation. DementiaCareCentral.com was developed with funding from the National Institute on Aging (Grant #R43AG026227). The CDT was originally developed in the 1900s to evaluate soldiers with head injuries. The numbers. The Clock Drawing Test (CDT) is a nonverbal screening tool in which the patient is asked to draw a clock. If you suspect a loved one may be showing signs of Alzheimer’s or another dementia, it's important to seek an assessment by a qualified clinician. The hands. Scoring: Score the clock based on the following six-point scoring system: Score Error(s) Examples Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Patient Instructions (Rouleau, Salmon et al. [30] Drawing Yes 1:00, 3:00, 9:15, 7:00 Subject asked to denote four different times. Drawings are scored based on degree of accuracy. It can often be one helpful component of a full assessment when a dementia diagnosis (or other cognitive impairment) is being considered. Make it large enough so that a child could read it.” If your loved one is distracted, or refuses to draw after having agreed to do so, you might consider these actions as a fail and seek further assessment from a doctor. Several research studies indicate that this test is an excellent tool to screen for cognitive impairment. There are several different times that people who administer this test may use, but many choose 10 minutes after 11. The Alzheimer’s Clock-Drawing Test (CDT) is a fast, simple way of spotting warning signs for Alzheimer’s disease and other related dementias that can be administered by non-professionals in the comfort of one’s home. Based on his performance, the nurse concludes that the patient: a. probably has Alzheimer's disease. The clinician (often a doctor, psychologist, or social worker) gives the person being tested a piece of paper with a pre-drawn circle on it and asks him to draw the numbers on the clock. Many forget after their anger after a period of rapport has been established. The test performance is judged based on the symmetry of the circle and the accurate placement of the numbers and the hands of the clock. Freedman et al. What Is a Neurological and Cognitive Exam? After your loved one draws the clock, you need to evaluate the image. For each clock, 2 points awarded for correct placement of each hand (1 point each), and a third point is given for … This also requires visual memory, or remembering what a clock looks like because you’ve seen one before. (1994) developed one of the initial CDT scoring protocols to establish normative data on clock drawing performance. What Memory and Thinking Tests Do Doctors Use to Evaluate Dementia? The advanced practice nurse administers the clock drawing test and the patient draws a distorted circular shape and places the numbers all on one side of the shape. How Well Does the SLUMS Test Screen for Dementia? If someone with neglect is asked to draw a clock, their drawing might show only the numbers 12 to 6, or all 12 numbers might be on one half of the clock face with the other half distorted or blank. The Mini-Mental State Exam (MMSE) – the MMSE is a multi-question test that asks the subject to demonstrate a wider array of knowledge and mental skills. His daughter reports that he has been very forgetful lately, and she is concerned that he might be "senile." Drawing a clock sounds basic and simple, but consider what’s required: If the clock is drawn correctly, that’s a pass; if there are mistakes, the person drawing has failed. "If a card has a vowel on one side, then it has an even number on the other side." – Verbal understanding Thank you, {{form.email}}, for signing up. Assess the clock, looking for abnormalities. The patient is given a pen, blank good-sized paper, all the time they need, and the request to “please draw the face of clock, with all the numbers on it, and please make it show the time ‘ten minutes after eleven.’” While a true diagnosis of Alzheimer’s or dementia obviously requires more than a few minutes of drawing with a pencil and paper, the CDT is useful for identifying issues in thinking ability that might indicate the presence of these illnesses. – Visual memory Sit your loved one down at the table and provide a single sheet of paper (a blank 8.5-by-11-inches sheet is fine) and a writing utensil. You, however, may notice that his decisions are not always appropriate. http://www.alz.org/professionals_and_researchers_14306.asp. Although the test may not seem scientific, it is backed by science and has contributed to earlier diagnoses and improved quality of life for persons with dementia. If someone has all the numbers on the right side, you could worry about left sided neglect. The clock drawing test has also been advocated over the MMSE as an office screening test for dementia in community clinics and in acute hospital settings. Cost – No expensive equipment or appointments required, just a pen or pencil and paper. Normal range of scores is 0 to 3. How to Administer the Clock Drawing Test: Step 1: Find a table and chair in a room that is familiar or free of distractions. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. This takes longer and can be distressing to the test-taker, and so the CDT usually comes before the MMSE. A quick and easy test of visuospatial ability, often used as a screening test for Alzheimer's disease or dementia. How the GPCOG Screening Tool Is Used to Screen for Dementia, The Trail Making Test and Its Use as a Screening Tool for Dementia. numbers) predrawn circle on it. The clock-drawing test is a quick screening method that helps evaluate mental functioning, and it has the benefit of being a fairly well-respected test due to the amount of research that supports its use. The following 10-point scoring system is typical: 10: … Nicholas R. Metrus, MD, is a board-certified neurologist and neuro-oncologist. If the clock looks essentially correct, but is messy (wavy or broken lines), this is more common in Huntington’s disease and vascular dementia than Alzheimer’s disease. As many as five, 10, or 20 points can be involved in some of the different scoring methods. She then tells him to draw the hands to show a specific time. However, a study published in the Danish Medical Journal outlines research that compared five of the most common ways to score the test. It requires less time to administer and to score. Get the best deals on clock numbers when you shop the largest online selection at eBay.com. Another method is to simply give the person a blank piece of paper and ask them to draw a clock that shows the time of 10 minutes after 11. Graphical Errors. Juby, A., Tench, S., and Baker, V. Canadian Medical Journal Association. Our organization has created an online version of the CDR Test here. Radical Wrongness. In the most severe cases of neglect, clock drawings may show all numbers drawn on the side of the clock ipsilateral to the lesion.5, 12 Clock drawing has not been used extensively in children. Furthermore, the clock drawing test is suitable for non-English speaking populations, whereas the MMSE does have … How Does the Digit Span Test Screen for Delirium and Dementia? Alzheimer’s disease and other dementias are progressive, meaning they get worse over time, and early detection is important because medications and therapies are more effective the sooner they begin. box below.). In how many different ways can you do this? While the clock-drawing test is generally quite effective at identifying cognitive concerns, there is not a consensus in the research community that it can consistently identify mild cognitive impairment or help distinguish between different forms of dementia (such as Alzheimer's disease and vascular dementia). Tolerability – Someone who bristles at testing may not mind being asked to perform this simple task. Spatial Errors. Find a table and chair in a room that is familiar or free of distractions. The Clock Drawing Test: a Review of Its Accuracy in Screening for Dementia. Its results are highly correlated with other mental status tests and with actual evidence of impairment. Put in all the numbers and set the time to 10 after 11”. He currently serves at the Glasser Brain Tumor Center in Summit, New Jersey. The advanced practice nurse administers the clock-drawing test and the patient draws a distorted circular shape and places the numbers all on one side of the shape. The Modified Clinical Dementia Rating (CDR) – this is another test that is fast, easy, and can be taken by family members and caregivers without medical training. 1) Draw a clock face. See images of other individuals Clock-Drawing Tests results here. There is no cure for Alzheimer’s disease and related dementias, but there are ways to make symptoms less destructive by preserving memory and focus. Performing only one test is likely to pick up only half of the cases of neglect. It is first important to say that while the CDT is useful and widely embraced by the medical community, it is just a small step in evaluating whether someone is developing dementia. Drawing a clock is not threatening to patient’s – who can become defensive and angry when they first realize the reason why they were dragged to the neuropsychologist in the first place. Based on his performance, the nurse concludes that the patient: a. probably has Alzheimer's disease. References Test Pre-drawn clock Time setting Scoring criteria and range Correlation with other measures Goodglass et al. A 78-year-old man is being evaluated in the geriatric clinic. Performing the clock-drawing test is one way to identify people who may be experiencing early signs of dementia, such as decreased executive functioning, but may not be displaying memory disturbances yet. It appears that they might preserve the current functioning for a limited time. A drawn clock is also a powerful symbol for friends and loved ones to see. It is often used in combination with other, more thorough screening tests, but even when used by itself, it can provide helpful insight into a person’s cognitive ability. A physical examination and brain scans are also part of the diagnosing procedure, and can also be both time-consuming and distressing. Hands may still be present in some fashion. Visuoconstructional Skills (Clock): Administration: Indicate the right third of the space and give the following instructions: “Draw a clock. (See Provide the Circle? Unfortunately for people with Alzheimer’s disease and other dementias, this thinking ability is compromised. Hearing an instruction and acting on it are difficult. There is greater emp… The clock-drawing test is a simple tool that is used to screen people for signs of neurological problems, such as Alzheimers and other dementias. Lily and Amy from Bow Brickhill School solved this problem using a method of trial and error, by adding consecutive numbers until they totaled a multiple of … The clock-drawing test has these advantages: One other very helpful aspect of this test, as published in the Canadian Medical Journal Association, is that it can detect problems in executive functioning even when someone scores well on the MMSE, a common screening tool. Set-up: Equipment required includes a blank sheet of paper, a sheet of paper with a clock on one side, a pen, and a chair/table for ease of drawing. It takes a little more effort to know that the “10 after” means drawing an arrow toward the 2. It does, however, help show whether a doctor’s appointment and further testing are necessary. These were described as critical clock-drawing errors and included the wrong time, no hands, missing numbers, number substitutions, repetition, and refusal. (Both methods have been shown as effective. There are as many as 15 different ways to score this test. People taking the test are asked to draw the numbers and arms of a clock as they would appear at a certain time of day, such as 2:15 p.m. What Is the Allen Cognitive Level Screen? This is why it’s best to begin with the simple CDT. On all of these tests, items missed on one side of space can reveal peri-personal neglect, both egocentric and allocentric. For more on the difference between pre-drawing the circle and not, see below.) It is often used in combination with other, more thorough screening tests, but even when used by itself, it can provide helpful insight into a persons cognitive ability. Other times, the tester will not provide the circle, nor say the words “number” or “hands,” to avoid giving hints. Often, family members are the first to suspect a cognitive impairment because they will see that evidence of poor executive functioning, while an MMSE test in a doctor’s office might not catch this. How the Clock-Drawing Test Screens for Dementia, Ⓒ 2020 About, Inc. (Dotdash) — All rights reserved. Indicate the top of the page. The clock drawing test is a way to test a person's visual and planning abilities. blank sheet of paper and a pencil. 1 point for the two hands of the clock. We will draw the clock hands to point at the appropriate points to display the current time. It also takes planning, or an understanding of the steps involved. Executive functioning can be impaired before any memory problems are evident, and identifying this early allows early treatment. If the clock doesn’t even look like a clock, like if there are letters or incorrect shapes added, this suggests confusion that is more indicative of Alzheimer’s disease than Huntington’s, Parkinson’s, vascular dementia or frontotemporal dementia. 3) Draw hand pointing to a given time. The Value of Clock Drawing in Identifying Executive Cognitive Dysfunction in People With a Normal Mini-Mental State Examination Score. The scientific community, including the Alzheimer’s Association, widely agrees that the CDT is a useful component of screening for cognition problems including dementia. Integrity of clock face is now gone (i.e., numbers missing or placed at outside of the boundaries of the clock … First, a person has to hear the instruction and then turn those words into the correct action. 5-1 Drawing of a clock face with circle and numbers is not intact. The number 12 must appear on top (3 points), there must be 12 numbers present (1 point), there must be two distinguishable hands (1 point), and the time must be identified correctly (1 point) for full credit. It is typically performed by having a person draw a clock and asking them to draw in the hands to show a particular time. This is why it’s a good idea if you have concerns. Content cannot be reproduced without permission.©1995-2020. Esther Heerema, MSW, shares practical tips gained from working with hundreds of people whose lives are touched by Alzheimer's disease and other kinds of dementia. If there are big gaps, numbers outside the circle, or numbers on only one side of the circle, this is more common in Parkinson’s disease with dementia, Lewy body dementia and vascular dementia, and less common in people with Alzheimer’s. Step 2: Instruct patient to draw numbers in the circle to make the circle look like the face of a clock and then draw the hands of the clock to read "10 after 11." You’ll be able to tell if it’s right or not, but because different dementias impact different parts of the brain, several aspects of the drawing are revealing: The Size of the Clock. If the clock is drawn abnormally, for example if the numbers are in the wrong places, this indicates the possibility of dementia and a need for further evaluation by a qualified doctor. The advanced practice nurse administers the clock-drawing test and the patient draws a distorted circular shape and places the numbers all on one side of the shape. It is suggested that one might put themselves out of visual range of the test taker in order to discourage questions. Speed – The test only takes a few minutes to administer and interpret. b. needs further evaluation. 2. c. probably has … If the person being tested is focused mostly on the time aspect—getting the hands pointed the right way so the clock is correct—to the detriment of the rest of the clock, this is more common in Alzheimer’s disease and Parkinson’s disease dementia than with other dementias. The most commonly utilized system of qualitative clock-drawing errors was described by Rouleau.1 He categorized five types of errors in addition to size of the clock (Figure 1): 1) graphic difficulties; 2) stimulus-bound response; 3) conceptual deficit; 4) spatial and/or planning deficit; and 5) perseveration. Additional research identified six features in this test that were important in successfully identifying problems in cognition. 4 Further distortion of number sequence. Relationships Among Number-Order Errors in the Clock Drawing Test The reversed clock phenomenon (RCP) is an extreme example, in which 1–12 are written counterclockwise. Clock Drawing Test rating I believe that this method can make different raters scores really similar. Notice that simply refusing to complete the test can be indicative of a problem. The reason it’s a good idea to ask for “10 minutes after 11,” is because the mind has some work to do. A 4-Minute Test: The Memory Impairment Screen (MIS). The AnalogClock Component Our clock will extend the Component class, and override the paintBackground() method to draw the clock … Neglect patients may also ignore the contralesional side of their body; for instance, they might only shave, or apply make-up to, the non … Further testing by a physician is essential before definitively saying that someone has Alzheimer’s disease or another dementia. There are significant benefits to the Clock-Drawing Test when compared to receiving a traditional medical diagnosis. 1 point for the clock circle. Say “Draw a clock that shows the time as 10 minutes after 11.” If further prompting is needed, it’s OK to be more specific: “Draw a circle to represent the face of the clock, then add the numbers, and then the hands.” The test will still work this way. The Clock-Drawing Test does not turn you into a clinician, able to expertly assess whether a loved one has Alzheimer’s disease. This simplest scoring method consists of giving one point if the task was completed correctly and zero points if the clock was not completed correctly. Drug May Boost Thinking Skills in People with Advanced MS; Most Americans Say They Will Get COVID-19 Vaccine, Survey Finds; 4) Can you draw two lines to divide the numbers so that the total of the numbers on each side of the lines are both multiples of six? 2) Place the numbers on the clock. Someone who may have dementia is asked to draw a clock showing the time as “10 minutes past 11.” Sometimes the subject is provided a pre-drawn circle and asked to fill in the numbers and hands. Fixating on Time. I try to rate with this algorithm and in 95% is very clear. paper with a clock on one side, a pen, and a chair/table for ease of drawing. The patient is asked to draw a clock face with all the numbers and hands and then to state the time as drawn. Individuals may be presented with a pre-drawn circle and need only place the numbers and hands on the clock face or the clock may be entirely self-generated. Allow as much time as needed to complete the task. It is best to provide a pencil with an eraser as this may help to lessen any frustration for the test taker. That single image can represent a loved one’s mental state, while the numbered score on a Q-and-A test just doesn’t have the impact of a clock with obvious mistakes. Simplicity – You don’t need training to ask someone to draw a clock and determine whether it’s correct or not. Instruct the patient to listen carefully to and remember 3 unrelated words and then to repeat the words. If there is an error in numbers of digits in the first three quadrants (spanning numbers 12 through 9), assign a score of 1. The clock is one of my favorite cognitive tasks. Also, as noted above, it appears to have the ability to detect problems with executive functioning that other tests may miss. For any error in the number of digits in the last quadrant, assign a score of 4. Alzheimer's Association. If the clock is drawn incorrectly (see “Reading the CDT” below), that is not cause for despair. Sign up for our Alzheimer’s and Dementia Newsletter and get your free recipe guide today. Some are quite elaborate and involve awarding points for the inclusion of every number, correctly ordered numbers, two clock hands, drawing the correct time, and for each of the correct numbers placed in the four quadrants. Denote four different times that people who administer this Test is likely pick... Systematically studied or standardized the other side. different times s appointment your... A specific time speed – the Test only takes a few minutes to administer and to score the only... The last quadrant, assign a score of 4 of visual range of most. Additional research identified six features in this Test may use clock drawing test all numbers on one side but many choose 10 minutes,,... 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Dementia diagnosis ( or other cognitive impairment ) is being considered diet shown... “ Reading the CDT was originally developed in clock drawing test all numbers on one side 1900s to evaluate the image: the impairment... This takes clock drawing test all numbers on one side and can be distressing to the 10 and the 11 Drawing. The appropriate positions who administer this Test may use, but it has never been studied. Whether it ’ s and Dementia Newsletter and get your free recipe guide today MIND clock drawing test all numbers on one side.