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The Clock-Drawing Test

by Dr.Peter Braunberger (2001)

Setting and scoring the test
Three easy steps
Scoring
Why do test?
Sensitive and specific
Example clock
References
Appendix of Scoring Methods
Mendez et al. 1992
Lam et al 1998
Wolf-Klein et al. 1989
Shua-Haim et al. 1996
Shulman et al. 1986
Sunderland et al. 1983
Setting and Scoring the Test
There are numerous versions of the clock-drawing test. They all involve asking the patient to draw
the face of a clock. Variations include providing a blank piece of paper or a paper with a predrawn (often 10 cm diameter) circle and asking the patient to draw the face of a clock. Further
questions from the patients may be politely deferred by repeating the request to draw the face of a
clock. Most variations of the test also include asking the patient to draw in the arms to denote
certain time. Many times have been used including, 3:00, 8:40, 2:45 and so on. They time 11:10
has been suggested as useful because of the distraction of "pull" of the numeral ten on the clock
when setting a time. Generally there is no time limit to the test, but the test usually takes only one
to two minutes.
3 Easy Steps
1. Provide patient with a piece of paper with a pre-drawn circle of approximately 10 cm in
diameter.
2. Indicate that the circle represents the face of a clock and ask the patient to put in the
numbers so that it looks like a clock.
3. Ask the patient to add arms so that the clock indicates the time "ten minutes after eleven."
Scoring

be able to continue independently. or a range of neurological and psychiatric illnesses. visual spatial organization (Lam et al 1998) memory and executive function (Estaban-Santillan et al 1998). The clock drawing test may complement other quick screening tests including the MMSE and is a component of the "7 Minute Neurocognitive Screening Battery" (Solomon et al 1998). The strength and weakness of the clock-drawing test lies in the number of cognitive. motor and perceptual functions required simultaneously for successful completion. conceptualization of time. Dementia Rating Scale and the Global Deterioration Scale. or categorizing errors conceptually. delirium. Royall (1996) suggests the executive function required for clock-drawing involves "control functions which guide complex goal-directed behaviour in the face of novel and irrelevant or ambiguous environmental cues". Common methods of scoring are as follows: Sulman et al 1986 Sunderland et al 1989 Wolf-Klein et al 1989 Mendez et al 1992 Shua-Haim et al 1996 Lam et al 1998 Why do the Test? The clock has been proposed as a quick screening test for cognitive dysfunction secondary to dementia. more than variations in administering the test itself. a grossly abnormal clock. auditory comprehension. More complex assessments include evaluating 20 traits. numerical knowledge. motor programming. visual memory. Most scoring systems are highly correlated with well-established measures including the MMSE. orientation. Perhaps the quickest scoring technique involves dividing the clock into four quadrants and counting the numbers in the correct quadrant. A quick screening for cognitive function may contribute an overall assessment of required investigations and resources for the patient. is an important indicator of potential problems warranting further investigation or resource allocation. . Many health care workers are faced with questions regarding the function and safety of patients in differing environments. semantic instruction. inhibition of distracting stimuli. Alternatively. and that similar demands are shared by independent living skills. for example. concentration and frustration tolerance (Shulman 2000) have all been highlighted as contributing to the successful clock. The completely normal clock is therefore a suggestion that a number of functions are intact and contributes to the weight of evidence that the patient may.There are a number of variations on scoring the clock.

however clock errors may predict many conditions in addition to dementia and it is important to maintain a wide differential diagnosis with clock errors. and therefore useful in early dementing processes. questions regarding the importance of minor errors remain. hemianopsia and sensory loss.e. Specificity (ie. et al. PJ. Sensitivity and specificity. Shulman (2000) suggests that serial clock drawing can be used to follow a progressive dementing process. They also highlight the placement of the arms as the most abstract feature of clock drawing. . 1991. Cognitive decline and psychotic state both contributed to poor scores in a clock-drawing test of elderly patients with a long-standing diagnosis of schizophrenia (Heinik et al 1997). absence of numbers and irrelevant spatial arrangement. References Borson. Clock drawing test in very mild Alzheimer's Disease. 12:526-532. The clock drawing test: utility for dementia detection in multiethnic elders. Sensitivity (i. grossly disorganized. 1996. S. (Gruber et al 1997). 20:140-145. 1999. Age and Ageing. Lam et al (1998) were unable to differentiate Alzheimer's Disease and Multi-infarct dementia according to clock errors. Gruber et al. EstebanSantillan et al (1998) suggest that minor clock errors are suggestive of a dementing process. Friedman. Clock drawing in acute stroke. A variety of psychiatric conditions contribute potentially to abnormal clock-drawing.While the grossly abnormal clock demands immediate attention. Journal of the American Geriatrics Society 46:1266-1269. 1998. Lee & Lawlor report on a subset of patients whose clock drawings improved significantly when treated for depression. International Journal of Geriatric Psychiatry. Errors following stroke may reflect spatial neglect. C. few false negatives) to dementia across many studies range from 75 to 92 percent depending on the population being assessed. or recovery from a toxic delirium. perseveration. These vary with the score on the clock drawing test. Common errors in Alzheimer's disease include perseveration. and averaged 85%. Esteban-Santillan. Journal of Gerontology Medical Sciences 54A:M534-M540. counter-clockwise numbering. A comparison of the clock drawing test and the Pfeiffer Short Portable Mental Status Questionnaire in a geopsychiatry clinic. likelihood ratio and positive predictive value have all been used to measure the potential value of the clock-drawing test as a screening tool (Shulman 2000). in addition to errors suggestive of cognitive dysfunction (Freidman 1991). few false positives) 65 to 96 percent with an average of 85%. Clock errors may be divided into categories including visuo-spatial. et al.

J. DR. Clock Drawing Interpretation Scale (CDIS) with the time "ten minutes past eleven. Shua-Haim et al. et al. State dependent nature of the clock-drawing task in geriatric depression. A seven minute neurocognitive screening battery highly sensitive to Alzheimer's disease. Clock drawing in Alzheimer's Disease: A novel measure of dementia severity. 1992. 15:548-561. reading and setting test in the screening of dementia in Chinese elderly adults. 55:349-355. 44:335. L. Mendez et al. Journal of the American Geriatric Society. 1997. Appendix: Scoring Methods Mendez et al. Solomon et al. et al. International Journal of Geriatric Psychiatry. Comparison of a clock drawing test in elderly schizophrenic and Alzheimer disease patients: A preliminary study. Journal of the American Geriatric Society.I. 1996. Sunderland. 1998. Journal of the American Geriatric Society.Heinik. Journal of Gerontology. Shulman. et al. Heinik. Royall. There is an attempt to indicate a time in any way. Lee. 1992. Archives of Neurology. Clock-drawing: Is it the ideal cognitive screening test? International Journal of Geriatric Psychiatry. Lam. All marks or items can be classified as either part of a closure figure. Score only if symbols for clock numbers are present. Clock-face drawing. Comments of the executive control of clock-drawing. 15:638643. Journal of the American Geriatric Society. 1996. 3. 1998. a hand or a symbol for clock numbers. 1995. et al. 2. A simple scoring system for clock-drawing in patients with Alzheimer's disease.P. T. 37:730-734. and Lawlor. Development of scoring criteria for the clock drawing task in Alzheimer's Disease. LCW. International journal of geriatric Psychiatry. 53B:353-357. G. 2000. 44:218-219. There is a totally closed figure without gaps ("the closure figure"). 1989. 1989. et al. Screening for Alzheimer's Disease by clock drawing. 2000. 40:1095-1099." 1. Wolf-Klein. 12:653-655. 37:725-729. J. K. 43:796-798. BA. Clock drawing test in elderly schizophrenia patients. Journal of the American Geriatric Society.. . Journal of the American Geriatric Society.

All numbers 1 to 12 are present. . The numbers do not go beyond the number 12. 14. 15. There are no substitutions for Arabic or Roman numerals. Incorrect spacing between numbers with subsequent inappropriate denotation of time. 13. rever sal of numbers. 1998. Noticeable impairment in line spacing. 9 Minimal evidence that a clock face is drawn. An "11" is present and is pointed out in some way for time. 7. 12. perseveration beyond twelve. drawing only to one side. perseveration beyond twelve. All hands radiate from the direction of a closure figure's center.4. Obvious errors in time denotation (arms misplaced. Slight impairment in spacing of lines or numbers. 10. 7 A recognizable attempt to draw a clock face but no clear denotation of time. Most symbols are ordered in a clockwise fashion. There are two distinct and separable hands. 5. 19. Three or more clock quadrants have one or more appropriate numbers per respective quadrant. hemiplegia and severe psychotics state). 8 Some evidence that a clock face is drawn. omitting most numbers) 6 Abnormal clock face drawing with inaccurate time denotation (eg reversal of numbers. Score 0 1 2 3 4 5 Description of clock Correct time with normal spacing. One hand is visibly longer than another hand. 6. 16. A "2" is present and pointed out in some way for the time. There is an attempt to indicate a time with one or more hands. 20. 10 No reasonable attempt to drawing a clock face (exclude gross visual disturbance. Most symbols are distributed as a circle without major gaps. numbers in wrong place) Abnormal clock-face drawing with inaccurate time denotation (eg. There are no repeated or duplicated number symbols. Scoring criteria for clock drawing test. All symbols are totally within a closure figure. All symbols lie about equally adjacent to a closure figure edge. 18. 9. misplaced numbers and drawing to one side and omitting most numbers). Lam et al. Seven or more of the same symbol type are ordered sequentially. 11. 17. All hands are totally within a closure figure. 8. Score only if one or more hands are present. misplaced numbers.

Wolf-Klein et al. Draws lines outside of circle c. 1996. Unable to indicate 3 o'clock 3. Writes words 3 o'clock d. Mildly impaired spacing of times b. Omits minute hand b. Draws in lines to orient spacing. Circles or underlines 3 f. Visual spatial a. Moderately impaired spacing of lines . Writes number three again e. Error in denoting time as 3 o'clock a. 1986. 2. Clock Type Description X Normal IX almost normal except for number VIII almost normal except for spacing VII very inappropriate spacing VI perseveration V absence of numbers IV counter clockwise rotation III other II irrelevant spatial arrangement I irrelevant figures Shua-Haim et al. Classification of clock errors with the time 1. Draws single line from 3 to 12 c. 1989. Simple scoring system Award one point for each of the following: Approximate drawing of the clock face Presence of numbers in sequence Correct spacial arrangement of numbers Presence of clock hands Hands showing approximately the correct time Hands depicting the exact time Shulman et al. Turns page while writing numbers so that some numbers appear upside down d. Visual spatial a.

months or seasons b. 1 Either no attempt or an uninterpretable effort is made. Writes words "clock" 5. Integrity of clock face is now gone (ie. times of day. Omits number c. 15 etc iii. 4. Dysgraphia 4. Hands may still be present in some fashion. Sensitivity and Specificity Sensitivity = (true positive)/(true positive + false negative) Specificity = (true negative)/(true negative + false positive) . 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 (ie. A PRIORI criteria for evaluating clock drawings. 2 Drawing reveals some evidence of instructions being received but only vague representation of a clock. Continues on past 12 to 13. Confused time. Severely disorganized spacing a. 10-6 Drawing of clock face with number and circle generally intact 10 Hands in correct position (ie. Hands are not present. Counter-clockwise iv. Draws picture of human face c. Repeats circle ii. Unable to make reasonable attempt at clock a. 14. use of digital display or circling numbers despite repeated instructions) 5-1 Drawing of clock face with circle and numbers is NOT intact 5 Crowding of numbers at one end of the clock or reversal of numbers. Exclude severe depression or psychotic state) Sunderland et al. 1983. numbers missing or placed outside of boundaries of the clock face) 3 Numbers and clock face no longer obviously connected in the clock drawing.b. Perseveration i. 4 Further distortion of number sequence. Hours hand approaching 3 o'clock) 9 Slight errors in placement of hands. writes in minutes.