Clock Drawing Test for Cognitive Screening - Research Paper Example

Introduction One of the difficulties that health care workers face with patients with advance diseases or those on long term care is cognitive impairment. Cognitive impairment affects a person’s ability to make plans, concentration and thought organization. A patient having cognitive impairment may require long term care or assisted living conditions because of their inability to take care of themselves. Patients with cognitive impairment may also fail to report illnesses or adverse side effects of medication making them susceptible to fall risks (Henderson, Scott, & Hotopf, 2007). There are many cognitive impairment assessment tools available that can be used to assess cognitive impairment or detect its early onset to elderly patients. But health care workers feel inadequate when performing these tests due to the complexity of the test or fears of upsetting patients with the unfamiliarity of the assessment tools. General Health workers also feel inadequacy when administering cognitive assessment tests because they have limited skills or training (Henderson, et al., 2007). One of the cognitive assessments tools that are being used is the Clock Drawing tests. Clock Drawing tests, or CDTs as it is more popularly known, is as a cognitive measuring tool used for patients with dementia, Alzheimer’s disease or for patients who are on long term care and may have degenerative diseases. The procedure for the test is for patients to draw the face of a clock, including the long hand and small hands of the clock to be set at a particular number to indicate the time and scored according to the accuracy of drawing the clock face. Other forms of CDT may require a patient to draw a cube instead of a clock face (Lavery , et al., 2005). Because the test has very simple instructions, it can be performed with little or no difficulty both for the patient and for the health care provider. Health care workers who administer the test will not have any fears of compromising the desired outcome of the assessment due to lack of training or unfamiliarity with the procedures. The test aims to check patients’ memory and attention to details on a commonplace object which is a clock. (Henderson, et al., 2007). The basic features of the test are for patients to either make free hand drawings or copy an exact model of a clock face. One of the aims for the CDT is to assess ones’ attention and memory. This test can be administered by staff or health care providers and requires little to no training. The test does not necessarily have to be administered or interpreted by a psychiatrist, but after the initial assessments made from the Clock Drawing test; further recommendation on follow up assessments can be made. Aside from drawing the face of a clock, patients are also made to recite the months of the year, either in a forward manner or a backward manner. (Blair et al, 2006). There are numerous ways on how the assessment test is scored and each one will be discussed in detail in the following pages. But to cite the known scoring methods used for the Clock Drawing tests, these are CLOX, Shulman, Manos and Rouleau (Blair, et al., 2006). The Clock Drawing test can be used as an effective measuring tool to assess a patients’ motor ability, judgment and planning, visual ability and constructive skills and the level of decline in these cognitive skills. The test is also able to differentiate patients with the early onset of dementia against those who have no cognitive impairment (Blair, et al., 2006). Assessment Procedure and Scoring Methods Source: Nagahama, et al., 2005, p. 391 Participants or patients are given sheets of paper and a pencil for the test. The paper usually has a circle already drawn on to it. The participants are then given instructions on what they should do or draw within the circle, which is a face of a clock. For patients who are not able to follow this instruction, they are shown a face of a clock and are asked to copy or draw the exact same figure in their paper as accurately as possible. Other procedures of the test may include setting the long hand and short hands of the clock to show a particular time, for example 7:30. (Blair et al, 2006). There are different methods used in scoring the Clock Drawing test. The Shulman scoring system uses a rating from zero to five, five being the perfect score. A score of four is given for those who were able to draw the clock face with minimal errors with the correct numbering sequence. A score of three is given when the clock hands are not in their correct placement. Two is given when the numbering on the face of the clock is disorganized making the setting of the clock hands denote inaccurate time. A score of one is given when the drawing of the numbers and clock hands are severely disorganized. While Zero is given to patients who are not able to make any representation or drawing of the clock face (Nagahama et al, 2005). Another way the Clock Drawing test is scored is through the scoring system set by Rouleau et al. that is quantitative and qualitative. The quantitative scoring uses a ten point scoring system where points are given based on the representation of the clock face (2 points), how the numbers are set on the drawing ( four points for the most accurate), and how accurate the clock hands are placed(four points). Qualitative scoring uses a six level method of scoring based on the errors of the proportions of the clock size to the drawings, plus other graphic distortions. Each qualitative criterion is given two points, for example a patient who is able to place the clock hands correctly on the time and is able to draw a straight and proportionate long and short clock hand is given two points (Blair, et al., 2006) A similar way of scoring the Clock Drawing test is the Manos 10-point scoring system. This scoring system can be used by general health workers and gives reliable results. The scoring is based on points systems on how accurate the numbers are placed on a clock face template and the positioning of the long hand and short hand of the clock to depict a particular time. The higher the points, the more accurate the patient is able to draw the clock face (Henderson, et al., 2007). For clinicians, the CDT is scored using CLOX and it has two parts, CLOX1 that uses free hand drawing with an assigned time set at 1:45 for example. The test is scored on how accurate the patients are able to place the long hand and short hand of a clock on the numbers to depict time. CLOX2 is a copy test where the participants are asked to copy a sample of a clock face. (Lavery , et al., 2005 The figures shown on table 5 demonstrate how the CLOX scoring is used in the Clock Drawing test and the variables in the result. The table also shows if a person’s educational attainment affect their ability in performing the assessment test. The sample data was gathered on a CDT assessment given to elderly Asian patients who have little or no education (Lin-Kiat Yap, et al., 2007). Source: Lin-Kiat Yap, et al., 2007, p. 197 Because of the tests relative simplicity, the test usually takes two minutes or less to complete. Unlike other cognitive impairment assessment tools that may take more than ten minutes to complete and may be complex for the patient to finish or respond. This makes the test ideal for patients with cognitive impairment and has short attention or concentration span (Lin-Kiat Yap, et al, 2007). The Advantages of using CDT in Assessing Cognitive Impairment There are different research studies that used CDT as a cognitive assessment tool. The group that participated in the study has different ethnic backgrounds, age and education. The validity of the CDT results in terms of cognitive assessment has been consistent with both groups where the test was able to differentiate those with and without cognitive impairment (Lin-Kiat Yap, et al., n.d.) People in hospice care and may not have dementia may experience confusion because of the effects of their medication or their diseases. CDT was able to assess patients who have trouble with memory by using the three-item recall. The assessment tool was able to get these results for patients admitted to a hospice and recommendations were made for further assessment of the patients. In terms of other cognitive assessment tools such as AMT and MMSE, the variances were results of poor reporting made by the nurses during the initial assessment. The patients’ responses showed improvement after forty-eight hours (Henderson, et al., 2007). One of the advantages of using the clock drawing test is that it is simple and the goal for the test is to draw an everyday commonplace object which is a clock. In terms of accuracy for the desired results, the disparity is very minimal. The subject of the test, which is a clock, transcends any language or ethnic background, so there is no need to translate the tests in various languages just to administer it to patients (Lin-Kiat Yap, et al., 2007). The test can also be administered even if the patient is in a low mood, and does not lean much on a patient’s knowledge unlike other assessment tests, such as the MMSE (Henderson, et al., 2007). Another advantage of using CDT for patient cognitive assessment is that the results can be read right away using any of the scoring methods that can be used to interpret the results of the test. (Lavery , et al., 2005) The test is also accepted by patients and those with visual or hearing impairments are the ones that were not able to finish the assessment because of their limitations. But for those patients without this limitation, they were able to finish the test (Blair, et al., 2006). There are a lot of cognitive assessment tools that can be used in gauging a patients’ possible decline to dementia or the onset of cognitive impairment. The most common assessment tool or test being used is the Memorial Delirium Assessment scale. This test or scale needs to be administered by a psychiatrist and may take more than ten minutes to finish the whole assessment process. Because of the time that it takes to accomplish, it can be partially finished because of the patients’ inability to concentrate on the test being administered (Henderson, et al., 2007). The same set backs are seen in the Confusion Assessment Method and the Delirium Rating scale. Aside from the length of time that it takes to complete the assessment test, these tests require training before it can be administered properly by health workers. The interpretation of the results also have to be made by a psychiatrist in order to validate the results of the given assessment exam. This is one of the advantages of the Clock Drawing test. Because of the assessment tools’ relative simplicity, the assessment may take a maximum of two minutes, adequate time for patients with cognitive impairment to concentrate and finish the task (Henderson, et al., 2007). The CDT results give reliable data for health care workers to assess if residents or patients need assisted living or long term care. But some tests on a group of residents are not able to make an assessment on the severity of the impairment and if the patient will need long term or short term care. Thus the need to make follow up assessments using other types of cognitive assessment tests in order to validate the patients need. The importance for health care workers to know what type of care the patient needs is so that the patient and their family can prepare for the costs of the care (Lavery , et al., 2005). Source: Lavery , et al., 2005, p. 930 The table above shows CDT and MMSE results conducted in a group of elderly patients staying in a hospice and were assessed for needing assisted living. But the CDT results were not used in the clinical assessment of patients included in the study in order to validate if the patients needed assisted living or transfer to another hospice that provides 24-hour care. In the study made, CDT was used only as an early assessment tool for patients with early cognitive impairment. Even if the results show the signs of early cognitive impairment, the data was still not used when the patients were considered for long term care or transfer to hospices with round the clock care. The study also did not validate the time needed for the care of the patients found to require assisted living or transfer to another hospice (Lavery , et al., 2005). The tests results show accurate results in terms of cognitive impairment. But other hospices and health care providers categorize the Clock Drawing test as an assessment test only and that in-depth follow up cognitive testing should be made for patients. There is a proposal in a study made that the Clock Drawing test can be used as an everyday assessment tool in order to find out who needs further assessment in terms of dementia among the general population of residents in a hospice setting. So even if the Clock Drawing tests give reliable data in terms of cognitive impairment, the data is insubstantial for diagnosis (Henderson, et al., 2007). One factor where the reliability of the CDT may be affected is when the test was administered to elderly Asian patients who don’t know how to read or write. The results in assessing if they have cognitive impairment may have been hampered by their inability to hold a pen correctly and their unfamiliarity or lack in skills with drawing or writing. Since CDT is also dependent on patients’ motor skills and vision, the results may be unreliable for this group of patients (Lin-Kiat Yap, et al., 2007). But even with the factors given with the education and ethnic background of the patients, the use of CDT was able to assess that the patients had or was progressing to cognitive impairment. But because there is no validated scoring method in Singapore, the data could not be used as a basis for early diagnosis of cognitive impairment (Lin-Kiat Yap, et al., 2007). When used together with MMSE the results on CDT is able to predict the early onset of cognitive impairment. Where MMSE is not able to gauge the degeneration in the case studies provided, CDT was able to provide that data (Lavery , et al., 2005). The Correlation of CDT with Other Cognitive Assessment Tools The Clock Drawing Tool can be scored with different rating scales. The most common rating scales used are the Manos and Shulman scoring methods. The Clock Drawing tool also shows correlation in terms of results with other cognitive assessment tools. Among them are the Mini Mental State Examination (MMSE) and AMTS or abbreviated mental test score (Henderson, et al., 2007). MMSE is used to assess patients with dementia or the onset of dementia. The disadvantage of using this assessment tool is that it can take ten to fifteen minutes to administer and needs to be translated if administered to non English speaking patients. The MMSE like the AMT is also leaning on a person’s knowledge and educational background, making it hard for elderly Asian patients who have different ethnic backgrounds and may have little or no education. It is also reliant on language and influenced by culture of the preparer of the exam. This influence also affects the results or interpretation of the answers given by the patient. The Clock Drawing test was able to overcome language and educational background issues when making cognitive assessment tests (Lin-Kiat Yap, et al., 2007). Even with the limitation of time administered to complete the assessment exam, MMSE is used together with CDT in order to validate both results to diagnose a patient with cognitive impairment. (BLAIR, et al., 2006) MMSE is widely used and accepted as a test for possible cognitive impairment. The result of this test is very accurate in terms of diagnosing elderly patients with dementia. The MMSE is a set of questions that a patient needs to answer and like CDT, it focuses on the memory and thought organization of a patient (Blair, et al., 2006). One disadvantage though of the MMSE is that it takes more time to complete than the CDT. The patient also has to be in a cooperative mood in order to get the desired answers in order to make a reliable assessment. A patient who is not willing to answer or has difficulty in concentration may affect the results in assessing cognitive impairment with MMSE. (Henderson, et al., 2007). Though the CDT is an effective tool in making cognitive impairment assessments, it cannot be used alone to make any diagnoses or recommendations. Other assessment tests have to be used in order to validate the results that CDT was able to give (Blair, et al., 2006). The following table shows data with both MMSE and CDT administered to a group of elderly Asian patients. The MMSE median score was adjusted for this group because of ethnic and language differences (Lin-Kiat Yap, et al., 2007). Source: Lin-Kiat Yap, et al., 2007, p. 195 In this table of results for patients given the CDT assessment exam, since the respondents are Asians and MMSE is language and ethnic dependent that may not be applicable for the patients, there was an adjustment made on the median of the MMSE results. The end result was that with CDT it was a more effective assessment tool rather than MMSE in making initial assessments for patients with cognitive impairment and was able to detect the onset of dementia among the respondents (Lin-Kiat Yap, et al., 2007). CDTs can also be used as an early predictive assessment tool for those with normal MMSE scores in terms of Alzheimer’s disease. In terms of scoring methods, the CLOX method shows a more correlation with MMSE than other scoring methods used in CDT. As simple as the test may seem which is to just draw a clock’s face, the data that health care workers are able to assess in this test is very valuable in the early detection of Alzheimer’s disease. There is also evident data where a patient may score normal in MMSE but have a score indicating the onset of cognitive impairment in CDT (Lavery , et al., 2005). The MMSE is used to assess if there will be cognitive impairment among elderly patients. While CDT measures patients’ inability to take care of themselves in a medical definition, particularly taking care of their health. In case studies, there may be differences in results but there is a correlation between the two tests that it can detect the early onset of cognitive impairment (Blair, et al., 2006). There are studies that show the reliability of CDT against MMSE. In a case study, some patients were able to draw clocks without any errors and others were not able to draw them accurately. This data shows that for those who were not able to draw the clocks as instructed may have cognitive impairment. But the MMSE scores for both patients are the same with indications of cognitive impairment (Nagahama, et al., 2005). Limitations on Administration of CDT The limitations seen by health care workers who administer the Clock Drawing test is when the participants are visually impaired and those who are too ill to take the tests. Another considered limitation on the assessment tool is when the patients are hearing impaired, because the instructions have to be verbally given to the patient taking the exam. There is also a bias seen on health workers when administering the test for those patients that they perceive that have cognitive impairment, even if they do not. The bias stems from previous cognitive assessment exams where the patient may have responded poorly. Patients with mobility issues in their upper extremities such as paralysis and tremors may have limitation issues with CDT. Their physical handicap may affect the reliability of the results of the test even if they have no cognitive impairment (Henderson, et al., 2007). There is also a problem with age because some of the patients included in case studies are younger and may not have the onset or stages of early cognitive impairment (Henderson, et al., 2007). Another limitation on the administration of the Clock Drawing tests and its outcome is the educational and ethnic background of the patient or participant. For elderly female Asians and elderly Asians as a whole, there is a noted poor performance when being assessed using the Clock Drawing Test because of their lack of education. This is particularly true for the female elderly patients. Since the test requires the participant to draw or write, this is a known limitation for elderly people with low economic backgrounds and females who were not given the opportunity for an education. The patients have to be coaxed out of their timidity in order to perform or respond to the test (Lin-Kiat Yap, et al., 2007). But this limitation in terms of education and ethnicity is short term and the administration of the assessment test in the future for this ethnic group promises to give improved scores, unlike with patients who are visually and hearing impaired. This limitation will not affect the reliability of CDT when it comes to assessing a patients cognitive skill (Lin-Kiat Yap, et al., 2007). The Clock Drawing test is also widely administered by health care practitioners in western countries, but is not yet widely accepted in General Practitioners’ offices in Asia. One reason why it is not widely accepted is because there is no validated objective scoring recorded in order to make the assessment tool a basis for assessing patients with cognitive impairment (Lin-Kiat Yap, et al., 2007). Conclusion The Clock Drawing test can be used as an important tool in assessing a patient with cognitive impairment. The test is also relatively simple and can transcend many cultures and languages. One of the many disadvantages of many cognitive assessment tools is that it is dependent on a desired result that is knowledge based and may be set in a different cultural or ethnic setting. A clock face can be seen in all countries, the same principles in telling or showing time does not differ even if it is in Asia or in Western countries. The CDT can also assess other cognitive functions that are overlooked in other cognitive assessment exams (Lin-Kiat Yap, et al., 2007). The only disadvantage that I can see is the number of scoring methods that is currently being used in order to interpret the results of the test. Because of this, there may be a possibility that some clinics may not use the results or its validity in making diagnoses because it used a different method in scoring the results. Though all scoring methods are able to predict the onset of cognitive impairment, it would be best if a set standard is imposed in order to avoid confusion (Lin-Kiat Yap, et al., 2007). Reading through the case studies presented in the articles, I found interesting that this assessment tool can be used with very accurate results. And the articles noted the acceptance of the physicians and the patients for this type of test because of its simplicity and it can be used to ease the work of general practitioners in making their cognitive assessment of their patients (Lin-Kiat Yap, et al., n.d.). The CDT is also presently categorized as an assessment tool and does not validate a patient with dementia or cognitive impairment. The results from CDTs have to be validated with other cognitive assessment tools such as MMSE in order to pronounce a patient having dementia or needing long term care and assisted living (Lavery , et al., 2005). In the case studies made, there is a general agreement on the findings that CDT is a reliable tool for assessing memory and cognitive function (Henderson, et al., 2007). But one of the great advantages of using this assessment tool is the time that it will take in order to complete the assessment, which is usually two minutes or less. Other assessment exams may require patients to sit through an assessment exam for more than ten minutes, which can cause due stress for both the patient and the health care worker administering the test. Because dementia patients with advance cognitive impairment may have difficulty in concentrating on a set task, this test is ideal in order for both the patient and the test administrator to finish the assessment test (Henderson, et al., 2007). In the case studies presented, there was nothing that I found unfavorable in terms of administering the CDT as a cognitive assessment tool. The other advantage that I see in this cognitive diagnostic test is that it can make the task for health care workers to make assessments because of its simplicity. And the test can be administered right away, with no special tools or materials needed in order to have patients take the test. (Lavery , et al., 2005) If there could be a recommendation that I could offer, that is to make the data show long term cognitive assessments. Some of the case studies were not able to make data show as to what extent the patient needs in terms of getting assisted living or hospice care (Lavery , et al., 2005). Patients who were asked to participate in the case studies in CDT were found to finish the assessment exam unlike with other cognitive assessment tests (Henderson, et al., 2007). References Blair, M., Kertesz, A., Mcmonagle, P., Davidson, W., & 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. Henderson, M., Scott, S., & Hotopf, M. (2007). Use of the clock-drawing test in a hospice population. Palliative Medicine, 21, 559-565. Lavery , L., Starenchak, S., Flynn , W., Stoeff, M., Schaffner, R., & Newman, A. (2005). The clock drawing test is an independent predictor of incident use of 24-hour care in a retirement community. Journal of Gerontology:Medical Sciences, 60A(7), 928-932. Lin-Kiat Yap, P., Ng, T., Niti, M., Yeo, D., & Henderson, L. (2007). Daignostic performance of clock drawing test by CLOX in an asian chinese population. Dementia and Geriatric Cognitive Disorders, 24, 193-200. Nagahama, Y., Okina, T., Suzuki, N., Nabatame, H., & Matsuda, M. (2005, March 30). Neural correlates of impaired performance on the clock drawing test in Alzheimer’s disease. Dementia and Geriatric Cognitive Disorders, 19, 390-396. Read More