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. 2022 Dec 31;22(1):509.
doi: 10.1186/s12883-022-03035-z.

Limits on using the clock drawing test as a measure to evaluate patients with neurological disorders

Raheleh Heyrani  1 , Atiye Sarabi-Jamab  2 , Jordan Grafman  3   4 , Nesa Asadi  1 , Sarvenaz Soltani  1 , Fatemeh Sadat Mirfazeli  5   6 , Mostafa Almasi-Dooghaei  7 , Seyed Vahid Shariat  1 , Amin Jahanbakhshi  8   9 , Tara Khoeini  7 , Mohammad Taghi Joghataei  10
Affiliations

Limits on using the clock drawing test as a measure to evaluate patients with neurological disorders

Raheleh Heyrani et al. BMC Neurol. .

Abstract

Background: The Clock Drawing Test (CDT) is used as a quick-to-conduct test for the diagnosis of dementia and a screening tool for cognitive impairments in neurological disorders. However, the association between the pattern of CDT impairments and the location of brain lesions has been controversial. We examined whether there is an association between the CDT scores and the location of brain lesions using the two available scoring systems.

Method: One hundred five patients with brain lesions identified by CT scanning were recruited for this study. The Montreal Cognitive Assessment (MoCA) battery including the CDT were administered to all partcipants. To score the CDT, we used a qualitative scoring system devised by Rouleau et al. (1992). For the quantitative scoring system, we adapted the algorithm method used by Mendes-Santos et al. (2015) based on an earlier study by Sunderland et al. (1989). For analyses, a machine learning algorithm was used.

Results: Remarkably, 30% of the patients were not detected by the CDT. Quantitative and qualitative errors were categorized into different clusters. The classification algorithm did not differentiate the patients with traumatic brain injury 'TBI' from non-TBI, or the laterality of the lesion. In addition, the classification accuracy for identifying patients with specific lobe lesions was low, except for the parietal lobe with an accuracy of 63%.

Conclusion: The CDT is not an accurate tool for detecting focal brain lesions. While the CDT still is beneficial for use with patients suspected of having a neurodegenerative disorder, it should be cautiously used with patients with focal neurological disorders.

Keywords: Diagnosis; Location of brain lesions; Screening tool; The clock drawing test.

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Conflict of interest statement

The authors declare no financial, personal or potential conflicts of interest.

Figures

Fig. 1
Fig. 1
Dendrogram showing hierarchical analysis of both qualitative and quantitative measures of CDT
Fig. 2
Fig. 2
Performance of CDT in 105 patients with brain lesion
Fig. 3
Fig. 3
Distribution of MoCA scores in 105 patients with brain lesions
Fig. 4
Fig. 4
The sensitivity and specificity of the CDT in cognitive impaired patients based on the qualitative CDT scoring
Fig. 5
Fig. 5
The sensitivity and specificity of the CDT in cognitive impaired patients based on the quantitative CDT scoring
Fig. 6
Fig. 6
The sensitivity and specificity of the CDT in cognitive impaited patients based on the combination of both qualitative and quantitative scoring systems
Fig. 7
Fig. 7
First series of the Correlation coefficient between the CDT and the subscales of the MoCA (full CDT scores)
Fig. 8
Fig. 8
Second series of Correlations between the CDT scores and the MoCA subscales (not full CDT scores)
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