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      Diagnostic value of digital clock drawing test in comparison with CERAD neuropsychological battery total score for discrimination of patients in the early course of Alzheimer’s disease from healthy individuals

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          Abstract

          The early detection of cognitive impairment or dementia is in the focus of current research as the amount of cognitively impaired individuals will rise intensely in the next decades due to aging population worldwide. Currently available diagnostic tools to detect mild cognitive impairment (MCI) or dementia are time-consuming, invasive or expensive and not suitable for wide application as required by the high number of people at risk. Thus, a fast, simple and sensitive test is urgently needed to enable an accurate detection of people with cognitive dysfunction and dementia in the earlier stages to initiate specific diagnostic and therapeutic interventions. We examined digital Clock Drawing Test (dCDT) kinematics for their clinical utility in differentiating patients with amnestic MCI (aMCI) or mild Alzheimer’s dementia (mAD) from healthy controls (HCs) and compared it with the diagnostic value of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) neuropsychological battery total score. Data of 381 participants (138 patients with aMCI, 106 patients with mAD and 137 HCs) was analyzed in the present study. All participants performed the clock drawing test (CDT) on a tablet computer and underwent the CERAD test battery and depression screening. CERAD total scores were calculated by subtest summation, excluding MMSE scores. All tablet variables (i.e. time in air, time on surface, total time, velocity, pressure, pressure/velocity relation, strokes per minute, time not painting, pen-up stroke length, pen-up/pen-down relation, and CDT score) during dCDT performance were entered in a forward stepwise logistic regression model to assess, which parameters best discriminated between aMCI or mAD and HC. Receiver operating characteristics (ROC) curves were constructed to visualize the specificity in relation to the sensitivity of dCDT variables against CERAD total scores in categorizing the diagnostic groups. dCDT variables provided a slightly better diagnostic accuracy of 81.5% for discrimination of aMCI from HCs than using CERAD total score (accuracy 77.5%). In aMCI patients with normal CDT scores, both dCDT (accuracy 78.0%) and CERAD total scores (accuracy 76.0%) were equally accurate in discriminating against HCs. Finally, in differentiating patients with mAD from healthy individuals, accuracy of both dCDT (93.0%) and CERAD total scores (92.3%) was excellent. Our findings suggest that dCDT is a suitable screening tool to identify early cognitive dysfunction. Its performance is comparable with the time-consuming established psychometric measure (CERAD test battery).

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          Clock-drawing: is it the ideal cognitive screening test?

          The clock-drawing test has achieved widespread clinical use in recent years as a cognitive screening instrument and a significant amount of literature relates to its psychometric properties and clinical utility. This review aims to synthesize the available evidence and assess the value of this screening test according to well-defined criteria. A Medline and Psycho-info literature search of all languages was done from 1983 to 1998 including manual cross-referencing of bibliographies. A brief summary of all original scoring systems is provided as well as a review of replication studies. Psychometric data including correlations with other cognitive tests were recorded. Qualitative aspects of the test are also described. Among published studies, the mean sensitivity (85%) and specificity (85%) of the clock-drawing test are impressive. Correlations with the Mini-Mental State Examination and other cognitive tests was high, generally greater than r = 0.5. High levels of inter-rater and test-re-test reliability and positive predictive value are recorded and despite significant variability in the scoring systems, all report similar psychometric properties. The clock test also shows a sensitivity to cognitive change with good predictive validity. The clock-drawing test meets defined criteria for a cognitive screening instrument. It taps into a wide range of cognitive abilities including executive functions, is quick and easy to administer and score with excellent acceptability by subjects. Together with informant reports, the clock-drawing test is complementary to the widely used and validated Mini-Mental State Examination and should provide a significant advance in the early detection of dementia and in monitoring cognitive change. A simple scoring system with emphasis on the qualitative aspects of clock-drawing should maximize its utility. Copyright 2000 John Wiley & Sons, Ltd.
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            The challenge of time: Clock-drawing and cognitive function in the elderly

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              Literature Review of the Clock Drawing Test as a Tool for Cognitive Screening

              Background/Aims: The Clock Drawing Test (CDT) is used in clinical practice for the screening of cognitive disorders. This systematic review aims to present and discuss the CDT scoring methods available in the literature, in order to find differences in administration and utility of the CDT. Methods: A literature search was carried out in Medline (1966 to June 2008), Psychinfo (1967 to June 2008) and EMBASE (1980 to June 2008). Results: All studies showed good interrater and test-retest reliabilities. The correlation with other standard screening tests was statistically significant in most studies, but the results were influenced by age, education and language. In studies that included patients with mild or questionable dementia, the CDT had a low sensitivity and variable specificity. Conclusion: The CDT has the characteristics of a good screening method for moderate and severe dementia. However, the scoring method used and potential confounders need to be taken into consideration.
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                Author and article information

                Contributors
                stephan.mueller@med.uni-tuebingen.de
                Journal
                Sci Rep
                Sci Rep
                Scientific Reports
                Nature Publishing Group UK (London )
                2045-2322
                5 March 2019
                5 March 2019
                2019
                : 9
                : 3543
                Affiliations
                [1 ]ISNI 0000 0001 2190 1447, GRID grid.10392.39, Department of Psychiatry and Psychotherapy, , Eberhard Karls University, ; Tübingen, Germany
                [2 ]ISNI 0000 0001 2190 1447, GRID grid.10392.39, Geriatric Center at the University Hospital, Eberhard Karls University, ; Tübingen, Germany
                [3 ]ISNI 0000 0000 9024 6397, GRID grid.412581.b, University Witten/Herdecke, Department of Psychology and Psychotherapy, ; Witten, Germany
                [4 ]Nuertingen-Geislingen University (HfWU), Institute of Research and Development in Art Therapies, Nuertingen, Germany
                [5 ]ISNI 0000 0004 0438 0426, GRID grid.424247.3, German Center for Neurodegenerative Diseases (DZNE), ; Tübingen, Germany
                [6 ]ISNI 0000 0001 2190 1447, GRID grid.10392.39, Section for Dementia Research, Hertie Institute for Clinical Brain Research and Department of Psychiatry and Psychotherapy, , Eberhard Karls University, ; Tübingen, Germany
                Article
                40010
                10.1038/s41598-019-40010-0
                6400894
                30837580
                cfec8aa2-b4b4-410b-bb2e-f145570adeb2
                © The Author(s) 2019

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

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                : 19 October 2018
                : 6 February 2019
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