A novel digital clock drawing test as a screening tool for perioperative neurocognitive disorders: A feasibility study

Abstract

Background We developed a digital clock drawing test (dCDT), an adaptation of the original pen and paper clock test, that may be advantageous over previous dCDTs in the perioperative environment. We trialed our dCDT on a tablet device in the preoperative period to determine the feasibility of administration in this setting. To assess the clinical utility of this test, we examined the relationship between the performance on the test and compared derived digital clock measures with the 4 A's Test (4AT), a delirium and cognition screening tool. Methods We recruited a sample of 102 adults aged 65 years and over presenting for elective surgery in a single tertiary hospital. Participants completed the 4AT, followed by both command and copy clock conditions of the dCDT. We recorded time‐based clock‐drawing metrics, alongside clock replications scored using the Montreal Cognitive Assessment (MoCA) clock scoring criteria. Results The dCDT had an acceptance rate of 99%. After controlling for demographic variables and prior tablet use, regression analyses showed higher 4AT scores were associated with greater dCDT time (seconds) for both command (β = 8.2, P = .020) and copy clocks (β = 12, P = .005) and lower MoCA‐based clock scores in both command (OR = 0.19, P = .001) and copy conditions (OR = 0.14, P = .012). Conclusion The digital clock drawing test is feasible to administer and is highly acceptable to older adults in a preoperative setting. We demonstrated a significant association between both the dCDT time and clock score metrics, with the established 4AT. Our results provide convergent validity of the dCDT in the preoperative setting.

Overview of the Complex Figure Test and Its Clinical Application in Neuropsychiatric Disorders, Including Copying and Recall

“…This method can more accurately reflect the drawing processing speed, motion control ability, and organization strategy and increase the understanding of the drawing strategy and executive function of the subject. Studies have shown that the digital clock drawing test can identify cognitive impairment with Alzheimer's disease ( 73 ), perioperative period ( 75 ), and Parkinson's disease ( 76 ). A recent study used the neural network employing information–theoretic feature selection approaches to perform machine learning analysis on the features collected by the digital clock drawing test.…”

Cognitive Assessment Tools Recommended in Geriatric Oncology Guidelines: A Rapid Review

“…A variety of scoring methods are used, complicating the interpretation of the literature [36]. Adaptations using a digital clock have been studied [83,86].…”

Digital clock drawing test metrics in older patients before and after endoscopy with sedation: An exploratory analysis

“…The development and use of the dCDT for use in the perioperative environment has been described in our previous work. 17 Briefly the dCDT is designed for use on an Apple 9.7" iPad ® (Apple Corporation, 6th generation), with an Apple pencil ® (Apple Corporation, 1st generation) on operating system iOS 12. For this study, an updated version of the dCDT software was created to incorporate the image of an ideal clock at the top of the drawing space for the "copy" component.…”

“…Our previous work shows that the dCDT is feasible and sensitive for preoperative cognitive screening. 17 Other work by Hizel et al, have detected postoperative neurocognitive changes at 3-months using a dCDT in orthopaedic patient populations without cognitive impairment. 22 The capacity of the dCDT to detect neurocognitive changes in the postoperative period for day endoscopy cases requires investigation.…”

“…13 A tool such as the digital clock drawing test (dCDT), which aims to address the shortcomings of longer, resource-intensive screening tools, may also be suitable. 17 Digital cognitive screening tools may address some of the limitations of existing paper-based tools (e.g., variable inter-rater reliability and integration with electronic medical records) and, therefore, increase the utility of cognitive screening in the perioperative setting.…”