Clock-Drawing Test Performance in the Normal Elderly and Its Dependence on Age and Education

Abstract

Objective: The main objective was to assess the relative frequency and types of errors on the clock-drawing test (CDT) in normal elderly subjects, and the dependence of their CDT performance upon their age and education. Method: The CDT performance of 242 normal elderly subjects, stratified according to age and education, was analyzed using both an absolute error count and a modified scoring sheet derived from 2 scales. Results: Normal elderly subjects (average age: 73.4 ± 8.4 years; mean Mini-Mental State Examination score: 27.7 ± 1.6) often have problems placing figures on the clock face and differentiating the clock hands correctly. The absolute number of errors increases with age and decreases with formal school education. A cumulative effect of both high age and a low level of school education yields substantially inferior scores, on the modified scale used, in comparison with younger subjects and those with higher levels of education. Conclusion: The frequent errors made by normal elderly subjects, and a combined negative influence of high age and low education level, suggest caution when interpreting the significance of CDT performance in the elderly.

Clock Drawing and Mini-Mental State Examination in Patients with Traumatic Brain Injury

“…In fact, when a cutoff score of 7 out of 10 was used to differentiate between TBI severity groups, the patients with mild TBI were significantly less impaired than the more severe TBI groups. Education and age have been found to be significant factors influencing performance on the CDT in the normal elderly (Hubbart et al, 2008;Paganini-Hill, Clark, Henderson, & Birge, 2001;Von Gunten et al, 2008). This was also the case in this study.…”

Clock drawing and rehabilitation outcome in hip fracture patients

“…Previous studies have shown that, when using the CDT as a screening tool, level of education on CDT performance, must be taken into consideration [20]. We found a significant difference between the two CDT groups as to the level of education.…”

The Framingham Heart Study Clock Drawing Performance: Normative Data from the Offspring Cohort

“…Studies report that CDT performance does show consistent decline with age (Crowe et al, 2010; Freedman et al, 1994; Spreen & Strauss, 1998; Hubbard et al, 2008; von Gunten, 2008), but no study to our knowledge has reported significant gender differences (Hubbard et al, 2008; Kim & Chey, 2010). While the CDT has been touted as an education unbiased (Lam et al, 1998; Shulman et al, 1986; Yamamoto, et al, 2004), and culture-fair (Marcopulos & McLain, 2003) test, the absence of educational or cultural bias is not clear.…”

“…Further, the education effect disappeared for the third scoring system when controlling for educational attainment, as measured by a reading test. von Gunten et al (2008) compared CDT performance across three educational levels and found poorer performance only among those in the lowest educational group that were over age 80. Ratliff et al (2003) and Hubbard et al (2008) proposed there is a “ceiling effect” of education on CDT scores because healthy elderly obtain relatively high CDT scores no matter their education level, so education effects are difficult to observe.…”

“…The discrepancy in results may lie in the use of scoring systems with differential levels of sensitivity. Recent studies (Crowe et al 2008; Crow et al 2010; Hubbard et al, 2008; von Gunten et al, 2008) have used scoring protocols that result in a wide range of scores (10–36 points). While a presumption might be made that more possible points reflects potential higher sensitivity in detecting cognitive change, in fact, it is the type of feature being scored that is a greater determinant of sensitivity rather than the number of points scored.…”