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Rehab Measures: Clock Drawing Test

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Clock Drawing Test Instructions (other languages available below) 

Title of Assessment

Clock Drawing Test 

Acronym

CDT

Instrument Reviewer(s)

Summary Date

 

Purpose

Assesses visuospatial and praxis abilities (may reflect both attention and executive dysfunction) 

Description

  • Consists of interviewer asking individuals to:
    • Draw a clock face
    • Place the numbers on the clock and
    • Draw hand pointing to a given time.
  • 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
  • Scoring consists of the evaluation of errors and/or distortions in the form of omissions of numbers and error in their placement such as perseverations, transpositions and spacing (McDowell & Newell, 1996).
  • Different scoring systems have a varying implications for interpretation
  • Simple quantitative scoring systems might be sufficient to discriminate presence versus absence of cognitive impairment as an initial screen (Lorentz et al, 2002)                                                           

Area of Assessment

Cognition 

Body Part

Not Applicable 

ICF Domain

Body Function 

Domain

Cognition; Sensory 

Assessment Type

Observer 

Length of Test

05 Minutes or Less 

Time to Administer

1-2 minutes

Number of Items

Not applicable 

Equipment Required

None necessary

Training Required

None necessary

Type of training required

No Training 

Cost

Free 

Actual Cost

Not applicable

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Stroke 

Populations Tested

  • Medical
  • Surgical
  • Alzheimer Disease
  • Stroke

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Medical Patients: (Manos & Wu, 1994)
  • A score of 7 identified 76% of outpatients with dementia

Normative Data

Acute Stroke: (Suhr et al, 1998; n = 176 (105 = stroke, 71 community based elderly); mean age of both sample > 70 years; mean time since stroke = 26.13 (9.11) days)
 
Means and Standard Deviations for 6 Clock Scoring Systems
 
Sunderland
Mendez
Rouleau
Watson~
Ishiai
Freedman
Normals
8.69* (1.9)
18.33* (1.9)
8.59* (1.5)
.83* (1.9)
3.49* (1.1)
13.14* (2.5)
Stroke
5.74 (2.3)
14.31 (4.4)
5.91 (2.4)
4.36 (2.5)
1.65 (1.5)
8.67 (4.4)
Right CVA
5.44 (2.0)
14.00 (4.1)
5.54 (2.4)
4.56 (2.4)
1.52 (1.4)
8.24 (4.4)
Left CVA
6.44 (2.8)
14.89 (5.0)
6.61 (2.5)
4.41 (3.0)
1.83 (1.6)
9.61 (4.2)
Bilateral
6.00 (2.2)
14.89 (5.0)
6.56 (2.2)
3.78 (2.7)
2.00 (1.4)
10.11 (3.0)
Anterior
6.27 (2.4)
14.47 (4.8)
6.20 (2.7)
4.00 (3.0)
1.73 (1.7)
9.27 (5.2)
Posterior
5.67 (2.0)
14.86 (3.1)
6.05 (2.1)
4.48 (2.6)
1.57 (1.4)

9.24 (4.0)

Cortical
5.73 (2.2)
13.70 (4.3)
5.61 (2.5)
4.46 (2.7)
1.55 (1.5)
7.82 (4.8)
Subcortical
5.87 (2.5)
14.70 (4.9)
6.20 (2.4)
4.00 (2.6)
1.93 (1.4)
9.23 (4.0)
CVA = Cerebrovascular accident
~For this scoring system, higher numbers mean worse performance.
*p > .001.

Test-retest Reliability

Medical Patients: (Manos & Wu, 1994)
  • Excellent test-retest reliability (r = 0.87)
Surgical Patients: (Manos & Wu, 1994)
  • Excellent test-retest reliability (r = 0.94)
Alzheimer Disease: (Tuokko et al, 1992; Mendez et al, 1992)
  • Adequate test-retest reliability (r = 0.70)
  • Excellent test-retest reliability
    (r = 0.78 - 3 months & 0.76- 6 months)

Interrater/Intrarater Reliability

Alzheimer Disease: (Tuokko et al, 1992; Mendez et al, 1992; Rouleau et al, 1992)
  • Excellent inter-rater reliability (r = 0.94 - 0.97 across three annual assessments)
  • Excellent inter-rater reliability (r = 0.94)
  • Excellent inter-rater reliability (r = 0.92- 0.97)

Surgical and Medical Patients: (Manos & Wu, 1994)

  • Excellent inter-rater reliability (r = 0.88 - 0.96)

Internal Consistency

Not Established

Criterion Validity (Predictive/Concurrent)

Acute Stroke: (Adunsky et al, 2002; n = 151, mean age = 73.7 (9.9) years, evaluated within 3 days of rehab admission)
  • Adequate concurrent validity with:
    • FIM- Cog Domain (r = 0.51)
    • MMSE (r = 0.59)

Construct Validity (Convergent/Discriminant)

Not Established

Content Validity

Not Established

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

Acute Stroke: (Nøkleby et al, 2008; n = 49; median age = 62 years; median time since stroke onset 38 days)
 
CDT Sensitivity, specificity and cut scores:
Assessment
Subtest
Cut-scores
Sensitivity (95% CI)
Specificity (95% CI)
Visuospatia function
CDT 7 minute
5/6
55 (34–75)
74 (58–91)
Attention and neglect
CDT 7 minute
6/7
55 (23–83)
42 (26–59)
Attention and neglect
CDT Manos
9/10
55 (23–83)

49 (31–66)

Attention and neglect
CDT Sunderland
9/10
55 (23–83)
42 (26–59)
Speed (non-affected side)
CDT Sunderland
9/10
74 (56–92)
59 (39–80)
Impaired > 1 domain
CDT Sunderland
9/10
63 (49–78)
67 (22–96)

Professional Association Recommendations

Considerations

  • Patients with multi-infarct dementia are more likely to make errors in time-setting than in number-spacing and greater levels of cognitive impairment are reflected by scoring scales that place more weight on this feature (Richardson & Glass, 2002). 
  • CDT performance may be influenced by:
    • Increasing Age
    • Level of Education
    • Presence of Depression (Ruchinskas & Curyto, 2003; Lorentz et al, 2002; Lourenco et al, 2008)
    • Visual neglect
    • Hemiparesis
    • Motor dyscoordination (Ruchinskas & Curyto, 2003)

Clock Drawing Test translations:

French (on p5):
http://fmc31200.free.fr/MG-liens/Neurologie/quatre_tests.pdf

German:
http://web48.s2.webseits.de/images/data/TEST-Teil6-Uhrentest-Sep05.pdf

Spanish:
http://marthacoronah.weebly.com/uploads/5/5/4/1/5541149/test_del_dibujo_del_reloj.pdf

These translations, and links to them, are subject to the Terms and Conditions of Use of the Rehab Measures Database. RIC is not responsible for and does not endorse the content, products or services of any third-party website, and does not make any representations regarding its quality, content or accuracy. If you would like to contribute a language translation to the RMD, please contact us at rehabmeasures@ric.org.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Adunsky, A., Fleissig, Y., et al. (2002). "Clock drawing task, mini-mental state examination and cognitive-functional independence measure: relation to functional outcome of stroke patients." Arch Gerontol Geriatr 35(2): 153-160. Find it on PubMed

Lorentz, W. J., Scanlan, J. M., et al. (2002). "Brief screening tests for dementia." Can J Psychiatry 47: 723-733. Find it on PubMed

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." Int J Psychiatry Med 24: 229-244. Find it on PubMed

McDowell, I. (2006). Measuring health: a guide to rating scales and questionnaires, Oxford University Press, USA.

Mendez, M. F., Ala, T., et al. (1992). "Development of scoring criteria for the clock drawing task in Alzheimer's disease." J Am Geriatr Soc 40: 1095-1099. Find it on PubMed

Nokleby, K., Boland, E., et al. (2008). "Screening for cognitive deficits after stroke: a comparison of three screening tools." Clin Rehabil 22(12): 1095-1104. Find it on PubMed

Richardson, H. E. and Glass, J. N. (2002). "A comparison of scoring protocols on the Clock Drawing Test in relation to ease of use, diagnostic group, and correlations with Mini-Mental State Examination." J Am Geriatr Soc 50: 169-173. Find it on PubMed

Rouleau, I., Salmon, D. P., et al. (1992). "Quantitative and qualitative analyses of clock drawings in Alzheimer's and Huntington's disease." Brain Cogn 18(1): 70-87. Find it on PubMed

Ruchinskas, R. and Curyto, K. (2003). "Cognitive screening in geriatric rehabilitation." Rehabilitation Psychology 48(1): 14-22.

Suhr, J., Grace, J., et al. (1998). "Quantitative and qualitative performance of stroke versus normal elderly on six clock drawing systems." Arch Clin Neuropsychol 13(6): 495-502. Find it on PubMed

Tuokko, H., Hadjistavropoulos, T., et al. (1992). "The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer disease." J Am Geriatr Soc 40: 579-584. Find it on PubMed

Year published

1993 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 12/18/2013 3:02 PM  by Jason Raad