CLOCK-DRAWING TEST CLOCK-DRAWING TEST AND MINI MENTAL AND MINI MENTAL

STATE EXAMINATION STATE EXAMINATION Presented By:Presented By: Iyan meyasdiIyan meyasdi

The clock-drawing test is a good screening test The clock-drawing test is a good screening test for dementia and cognitive dysfunction with the for dementia and cognitive dysfunction with the possible exception of cases of very early possible exception of cases of very early Alzheimer's disease. The test has a high Alzheimer's disease. The test has a high correlation with the MMSE and other tests of correlation with the MMSE and other tests of cognitive dysfunction. Its value in diagnosing cognitive dysfunction. Its value in diagnosing unilateral neglect and focal brain damage unilateral neglect and focal brain damage requires further study. It is easy to administer, is requires further study. It is easy to administer, is not threatening to the patient and takes very not threatening to the patient and takes very little time. It is easy to document graphically in little time. It is easy to document graphically in clinical records and it can be used to document clinical records and it can be used to document deterioration over time in dementia patients. deterioration over time in dementia patients. Normal clock-drawing ability reasonably excludes Normal clock-drawing ability reasonably excludes cognitive impairment.cognitive impairment.

The clock-drawing test is used for screening for The clock-drawing test is used for screening for cognitive impairment and dementia and as a cognitive impairment and dementia and as a measure of spatial dysfunction and neglect. It measure of spatial dysfunction and neglect. It was originally used to assess visuo-constructive was originally used to assess visuo-constructive abilities but we know that abnormal clock drawing abilities but we know that abnormal clock drawing occurs in other cognitive impairments. Doing the occurs in other cognitive impairments. Doing the test requires verbal understanding, memory and test requires verbal understanding, memory and spatially coded knowledge in addition to spatially coded knowledge in addition to constructive skills. Education, age and mood can constructive skills. Education, age and mood can influence the test results, with subjects of low influence the test results, with subjects of low education, advanced age and depression education, advanced age and depression performing more poorly.performing more poorly.

Different ways of performing the Different ways of performing the clock-drawing testclock-drawing test

Clock drawing can be performed in different ways and the Clock drawing can be performed in different ways and the scoring also varies. The subject is presented with a white scoring also varies. The subject is presented with a white paper with the instructions to draw a clock. There is no time paper with the instructions to draw a clock. There is no time limit. In the free-drawn method, the subject is asked to limit. In the free-drawn method, the subject is asked to draw a clock from memory. In the pre-drawn method, the draw a clock from memory. In the pre-drawn method, the subject is presented with a circular contour and is expected subject is presented with a circular contour and is expected to draw in the numbers on the clock face. Sometimes the to draw in the numbers on the clock face. Sometimes the subject is asked to draw the hands at a fixed time, often 10 subject is asked to draw the hands at a fixed time, often 10 past 11, but in many cases the hands are excluded. In still past 11, but in many cases the hands are excluded. In still another method the subject is asked only to set the hands another method the subject is asked only to set the hands at a fixed time on a pre-drawn clock, complete with contour at a fixed time on a pre-drawn clock, complete with contour and numbers and numbers

traced a four-inch diameter circle in the chart traced a four-inch diameter circle in the chart and then asked the patient to write in the and then asked the patient to write in the numbers that appear in the face of a clock. numbers that appear in the face of a clock. When they had finished that task, asked When they had finished that task, asked them to make the clock read ten minutes them to make the clock read ten minutes after 11, consciously avoiding mention of the after 11, consciously avoiding mention of the hands of a clock. This is the entire procedure hands of a clock. This is the entire procedure for the administration of the 10-point clock for the administration of the 10-point clock test (Manos and Wu, 1994) test (Manos and Wu, 1994)

produced a clear plastic template, four inches in diameter produced a clear plastic template, four inches in diameter and divided into eighths, both to trace the circle and score and divided into eighths, both to trace the circle and score the test. the test.

To score, the clock is divided into eighths, beginning with a To score, the clock is divided into eighths, beginning with a line through the number 12 and the center of the circle. (If line through the number 12 and the center of the circle. (If the 12 is missing, its position is assumed to be the 12 is missing, its position is assumed to be counterclockwise from the 1 at a distance equal to that counterclockwise from the 1 at a distance equal to that between the 1 and 2.) Any straight edge may be used to between the 1 and 2.) Any straight edge may be used to divide the clock into eighths. This is accomplished more divide the clock into eighths. This is accomplished more quickly by placing the clear, flat plastic template over the quickly by placing the clear, flat plastic template over the circle with a linecircle with a line through the number 12. through the number 12.

One point each is given for the numbers 1, 2, 4, 5, 7, 8, 10, One point each is given for the numbers 1, 2, 4, 5, 7, 8, 10, and 11 if at least half the area of the number is in the proper and 11 if at least half the area of the number is in the proper octant of the circle relative to the number 12. One point octant of the circle relative to the number 12. One point each is given for an obvious short hand pointing at the 11 each is given for an obvious short hand pointing at the 11 and an obvious long hand pointing to the 2. The difference and an obvious long hand pointing to the 2. The difference in the length of the hands must be obvious at a glance. in the length of the hands must be obvious at a glance.

A score of 10 suggests that cognitive A score of 10 suggests that cognitive impairment (CI) is unlikely, although impairment (CI) is unlikely, although isolated short-term memory isolated short-term memory impairment such as that seen with impairment such as that seen with carbon monoxide poisoning may be carbon monoxide poisoning may be missed. A score of eight or nine must missed. A score of eight or nine must be interpreted clinically. However, a be interpreted clinically. However, a score of less than eight indicates score of less than eight indicates almost CI, and a score of less than almost CI, and a score of less than five indicates prominent impairment. five indicates prominent impairment.

Mini mental State examinationMini mental State examination Effective screening for cognitive Effective screening for cognitive

impairment requires assessment of impairment requires assessment of multiple aspects of mental multiple aspects of mental functioning, including orientation, functioning, including orientation, short-term memory, receptive and short-term memory, receptive and expressive language ability, expressive language ability, attention, and visual-spatial ability. attention, and visual-spatial ability.

Questions (Total of 30 points)Questions (Total of 30 points)

- Orientation (10 points) - Orientation (10 points) Patient identifies time and place Patient identifies time and place

- Registration (3 points) and Recall (3 - Registration (3 points) and Recall (3 points) points) Patient recalls objects at 1 and 5 minutes Patient recalls objects at 1 and 5 minutes

- Attention and Calculation (5 points) - Attention and Calculation (5 points) Patient spells a word backwards Patient spells a word backwards

- Language (9 points) - Language (9 points) Tests processing language Tests processing language

Interpretation of Mini-mental State Score (Maximum: 30)Interpretation of Mini-mental State Score (Maximum: 30)

Normal score: 24 or higher Normal score: 24 or higher Educational and Age Norms Educational and Age Norms

Fourth Grade Education Fourth Grade Education – Ages 18 to 69: Median MMSE Score 22-25 Ages 18 to 69: Median MMSE Score 22-25 – Ages 70 to 79: Median MMSE Score 21-22 Ages 70 to 79: Median MMSE Score 21-22 – Age over 79: Median MMSE Score 19-20 Age over 79: Median MMSE Score 19-20

Eighth Grade Education Eighth Grade Education – Ages 18 to 69: Median MMSE Score 26-27 Ages 18 to 69: Median MMSE Score 26-27 – Ages 70 to 79: Median MMSE Score 25 Ages 70 to 79: Median MMSE Score 25 – Age over 79: Median MMSE Score 23-25 Age over 79: Median MMSE Score 23-25

High School Education High School Education – Ages 18 to 69: Median MMSE Score 28-29 Ages 18 to 69: Median MMSE Score 28-29 – Ages 70 to 79: Median MMSE Score 27 Ages 70 to 79: Median MMSE Score 27 – Age over 79: Median MMSE Score 25-26 Age over 79: Median MMSE Score 25-26

College Education College Education – Ages 18 to 69: Median MMSE Score 29 Ages 18 to 69: Median MMSE Score 29 – Ages 70 to 79: Median MMSE Score 28 Ages 70 to 79: Median MMSE Score 28 – Age over 79: Median MMSE Score 27 Age over 79: Median MMSE Score 27