Cultural influence on clock drawing test: A systematic review

Abstract

Objective: Dementia among migrants is an emerging phenomenon worldwide and the development of neuropsychological tests sensitive to cultural differences is increasingly regarded as a priority. The Clock Drawing Test (CDT) is one of the most used screening tools for the detection of cognitive decline. Nevertheless, there is still a debate about its adoption as a cross-cultural assessment. Methods: To identify cultural variables influencing performance at CDT, we performed a systematic review of literature on three databases of all studies considering the role of at least one of the following: (1) language; (2) education; (3) literacy; (4) acculturation; and (5) ethnicity. Results: We extrapolated 160 analyses from 105 studies. Overall, an influence of cultural determinants on performance at CDT was found in 127 analyses (79.4%). Regarding specific cultural factors, 22 analyses investigated the effect of ethnicity on CDT scores, reporting conflicting results. Only two scoring systems turned out to be sufficiently accurate in a multicultural population. Language influenced performance in only 1 out of 8 analyses. A higher level of education positively influenced test performance in 118 out of 154 analyses (76.6%), and a better quality of education in 1 analysis out of 2. A negative influence of illiteracy on CDT performance emerged in 9 out of 10 analyses. Acculturation affected performances at CDT in 1 out of 2 studies. Conclusions: Based on the present findings, caution is needed when using CDT in a multicultural context, even if it requires limited linguistic competence.

Diagnostic Accuracy of the Swedish Version of the Multicultural Cognitive Examination for Cognitive Assessment in Swedish Memory Clinics

“…This study also showed that CDT, but not CRT, was affected by education and the foreign-born or Swedish-born status, which agreed with Nielsen et al [29]. Moreover, Maestri et al [46] suggested that the application of the CDT in a multicultural population should be performed with care.…”

FaIRClocks: Fair and Interpretable Representation of the Clock Drawing Test for mitigating classifier bias against lower educational groups

“…Previous literature indicates that CDT performance is affected by age, education level, race, and ethnicity 18 . A systematic review showed that higher levels of education positively affected clock drawing performance, while illiteracy hindered clock construction in several studies 19 . Specifically, individuals with fewer years of education tend to exhibit more digit placement errors and increased omission of clock hands 20 , 21 .…”