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RehabMeasures Instrument

Clock Drawing Test

Purpose

The CDT assesses visuospatial and praxis abilities (may reflect both attention and executive dysfunction). 

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Instrument Details

Acronym CDT

Area of Assessment

Cognition

Assessment Type

Observer

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Stroke Recovery

Key Descriptions

  • Consists of interviewer asking individuals to:
    1) Draw a clock face.
    2) Place the numbers on the clock.
    3) 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 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).

Time to Administer

1-2 minutes

Required Training

No Training

Age Ranges

Adults

18 - 64

years

Elderly Adult

65 +

years

ICF Domain

Body Function

Measurement Domain

Cognition
Sensory

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!

Stroke

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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.

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)

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)

Alzheimer's Disease and Progressive Dementia

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Test/Retest Reliability

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 (= 0.94 - 0.97 across three annual assessments)
  • Excellent inter-rater reliability (r = 0.94)
  • Excellent inter-rater reliability (r = 0.92- 0.97)

Mixed Populations

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Cut-Off Scores

Medical Patients: (Manos & Wu, 1994)

  • A score of 7 identified 76% of outpatients with dementia

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)

Interrater/Intrarater Reliability

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

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

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

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