CLOCK DRAWING TEST

Cognitive function is a broad term that refers to mental processes involved

in the acquisition of knowledge, manipulation of information, and reasoning. Cognitive
functions include the domains of perception, memory, learning, attention, decision making,
and language abilities. Perception is the organization, identification, and interpretation of
sensory information in order to represent and understand the presented information or
environment. Memory is an important cognitive process that allows people to encode, store,
and retrieve information. It is a critical component in the learning process and allows people
to retain knowledge about the world and their personal histories. Learning requires cognitive
processes involved in taking in new things, synthesizing information, and integrating it with
prior knowledge. William James wrote that attention “is the taking possession by the mind, in
clear and vivid form, of one out of what may seem several simultaneously possible objects or
trains of thought It implies withdrawal from some things in order to deal effectively with
others. Language and language development are cognitive processes that involve the ability
to understand and express thoughts through spoken and written words. It allows us to
communicate with others and plays an important role in thought. Decision-making is
regarded as the cognitive process resulting in the selection of a belief or a course of action
among several possible alternative options, it could be either rational or irrational. These
cognitive functions have an important role in our day-to-day functioning, which could be
disrupted by various neurological disorders that affect the brain as well as the nerves found
throughout the human body and the spinal cord. These structural, biochemical or electrical
abnormalities in the brain, spinal cord or other nerves can result in a range of symptoms.

Visual-spatial ability is a broad term that emphasizes processes

such as image generation, storage, retrieval, and transformation and includes a collection of
skills in the areas of spatial relations, visualization, visual memory, closure speed, and spatial
scanning. Because visual-spatial ability is a multidimensional construct, it is possible for an
individual to have a relative strength in one area of visual-spatial ability (e.g., visual memory
of objects) and a relative weakness in another (e.g., spatial relations; Mather & Wendling).
The visual environment can be organized into a meaningful whole through visual perception.
Visual perception of an object requires the integration of several features, such as color,
depth, separating shapes and objects from their background, and form constancy. Visual

82
object recognition involves integrating visual perception with previous knowledge of known
objects. Spatial ability, on the other hand, involves the integration of visual scanning of
space, mental representation of the relative position of one’s body parts in space, ability to
perform the necessary movements for a task, and understanding of the topographical
environment . Visual-spatial ability is an area typically measured as part of
neuropsychological examinations and may include the assessment of perceptual skills,
constructional skills, and spatial awareness.

Brain Disorders are primarily classified into Alzheimer’s disease, Dementias,

Brain Cancer Epilepsy and Other Seizure Disorders, Parkinson’s and Other Movement
Disorders, Stroke and Transient Ischemic Attack (TIA) Alzheimer’s disease (AD), the most
common and fastest growing form dementia in the aging population, accounts for more than
60 percent of all dementia-related diseases. Irreversible and progressive, AD slowly destroys
memory and thinking skills and, eventually, the ability to carry out the simplest tasks of daily
living. Although treatment can help manage the symptoms of AD, there is no cure for the
disease. AD begins deep in the brain where healthy neurons begin to work less efficiently and
eventually die. This process gradually spreads to the brain’s learning and memory center—
the hippocampus—and other areas of the brain, which also begin to shrink. At the same time,
beta-amyloid plaques and neurofibrillary tangles begin to spread throughout the brain.
Scientists believe these brain changes begin 10-20 years before the signs or symptoms of the
disease appear. Dementia is a syndrome that involves memory loss and decline in intellectual
functioning that is severe enough to interfere with an individual’s ability to perform routine
tasks. More specifically, it involves impairment in two or more areas of thinking and mental
ability, for example chronic forgetfulness, planning, organizing and decision making, and
confusion.

Frontotemporal dementia (FTD), a common cause of dementia, is a group of

disorders that occur when nerve cells in the frontal and temporal lobes of the brain are lost.
This causes the lobes to shrink. FTD can affect behavior, personality, language, and
movement. These disorders are among the most common dementias that strike at younger
ages. Symptoms typically start between the ages of 40 and 65, but FTD can strike young
adults and those who are older. FTD affects men and women equally. The most common
types of FTD are Frontal variant that affects behavior and personality. Primary progressive
aphasia. Aphasia means difficulty communicating. This form has two subtypes, Progressive
nonfluent aphasia, which affects the ability to speak and Semantic dementia, which affects

83
the ability to use and understand language. A less common form of FTD affects movement,
causing symptoms similar to Parkinson disease or amyotrophic lateral sclerosis.

Dementia Affects Visuospatial Abilities by affecting Depth Perception, Increased Risk

of Wandering, Recognizing Faces and Locating Objects, Difficulty Driving and reading etc.
Dementia can affect depth perception, making it more difficult to navigate tasks such as
going downstairs and thus increasing the risk of falls. Activities of daily living such as getting
into a bathtub, getting dressed or feeding oneself can also become more challenging. Persons
with dementia can also become easily lost and wander, even in very familiar environments.
They might not recognize the path home that they've taken every day for many years, or be
able to locate the bathroom in the middle of the night. Visuospatial changes may also
contribute, along with the cognitive symptoms of dementia, to the inability to recognize faces
or find objects that are in plain sight. Driving may become more difficult as dementia
develops, in part because of changes in the ability to understand spatial relationships. For
example, navigating a turn, changing lanes or parking a car could become a significant
challenge due to a decline in visuospatial abilities. As dementia progresses, the difficult
decision to quit driving usually must be mad The ability to read may also decline, in part due
to visuospatial changes, as well as a decline inability to remember how to read or
comprehend the meaning of the words.

Another Disorder that has a severe effect on an individual’s Visual spatial ability is
Constructional Apraxia. Constructional apraxia refers to the inability of patients to copy
accurately drawings or three-dimensional constructions. It is a common disorder after right
parietal stroke, often persisting after initial problems such as visuospatial neglect have
resolved. A key deficit in constructional apraxia patients is the inability to correctly copy or
draw an image. There are qualitative differences between patients with left hemisphere
damage, right hemisphere damage, and Alzheimer's disease. Alzheimer's disease patients
with constructional apraxia have unique symptoms. Their drawings contain fewer angles,
spatial alterations, a lack of perspective and simplifications, which are uncharacteristic of left
hemisphere or right hemisphere patients. Constructional apraxia cannot be localized to a
specific hemisphere or cerebral area because drawing and constructional tasks require both
perceptual and motor functioning. It has been linked to parietal lesions in the left and right
hemisphere, stroke and Alzheimer's disease. Initially, researchers tried to isolate the cause to
left hemisphere lesions in the parietal lobe because of its similarities to Gerstmann syndrome;
however, lesions in the dorsal stream also result in visual agnosia and a piecemeal drawing.

84
Although constructional apraxia can result from lesions in any part of the brain, it is most
commonly associated with lesions in the parietal-occipital lobes. Constructional apraxia is
common after right parietal stroke and it continues after visuospatial symptoms have
subsided. Patients with posterior and parietal lobe lesions tend to have the most severe
symptoms.

The visual special deficits of people suffering from constructional apraxia can be studied with
the help of Simple Clock Drawing Test. Such drawings can be usually classified as bizarre
clocks, major spacing abnormality and minor spacing abnormality.

bizarre clocks: These range from a few uninterpretable squiggles to perseverative use of
numbers all around the perimeter. Some patients could not apply themselves well enough to
make any mark at all

major spacing abnormality: These clocks contain all the correct numbers but are spaced very
poorly. All 12 numbers may be bunched around one side of the clock and if the bunching
finishes with the 11 (or 12 if start before the 9 o'clock) horizontal, a major spacing
abnormality is present. There may be several bunches of numbers. One number may be
omitted or an extra number (usually a second 12) may be added. Multiple number omissions
or additions belong to Class 1.

minor spacing abnormality: The numbers are correct but spacing is slightly abnormal. If the
numbers finish above the 9 o'clock horizontal it is included here When a more major spacing
abnormality is recognized spontaneously (usually at the 3 or 6 location) and corrected
normally for the remainder of the clock, or when there are single number errors with normal
spacing, they are included here.

85
The common Clock drawings produced by patients suffering from Constructional
Apraxia

86
 Introduction to the Test

The clock test is used for screening for cognitive impairment and dementia and as a
measure of spatial dysfunction and neglect. It was originally used to assess visuo-constructive
abilities but we know that abnormal drawing occurs in other cognitive impairment. Doing the
test requires verbal understanding, memory and spatial coded knowledge in addition to
constructive skill. Education, age and mood of the individual can influence the test results.
The subjects of low education, advanced age and depression perform more poorly. Visuo-
spatial deficits are a common and early sign of dementia and a clock drawing test is
suggested as a screening tool for dementia.

CDT is correlated with MMSE results in patients with various kinds of cognitive
dysfunction and elderly medical and surgical patients. Constructional apraxia may occur with
lesions in the left parietal lobe and more frequently with the right parietal lobe. It can also be
observed early in times of Alzheimer’s disease. The Clock drawing test correlated strongly
with the test of constructional apraxia and to global deterioration scale. CDT has become one
of the most commonly used cognitive screening instruments because this is an instrument
following characteristics: quick administration, acceptable to the patients, easy to score,
relatively independent of culture, language and religion (Spoken/written instruction nor a
patient who cannot write.).

Good inter score rate and test- retest reliability, there are high levels of sensitivity and
specificity. Correlation with measures of severity and other dementia measuring score with
high predictable validity. Also test a wide range of cognitive skills including comprehension,
visual memory, planning reconstruction, visual spatial motor programming execution,
numerical knowledge, abstract thinking, and inhibition of full by perceptual features,
concentration and frustration.

It is easy to administer and isn’t threatening to patients. Can be used as a screening

tool and proven to be clinically useful to differentiate among elderly patients with neuro-
vascular disorder, depression and even schizophrenia.it can be used with patients with stroke
and also for those with speech difficulties but who have sufficient comprehension to

87
understand the task. It should not be used in patients who cannot understand spoken or
written instruction nor with the patients who cannot write.

METHOD

Aim

To assess the cognitive impairment and spatial dysfunction of the participants using the clock
drawing test.

Participant Details

Name –PM

Age -69

Gender - Female

Education – High School Education

Materials Required

Blank paper with circle drawn

Writing materials

Manual

Administration

Seat the participant comfortably and establish the rapport and the following
administrations are given: The subject is presented with a circle counter that is around 8.5 x
11 inch, sheet of paper number with instruction to “draw the hours of the clock, after putting
all the numbers. Place the hands of the clock to represent the time ‘forty-five minutes past 10
‘o’ clock’.

Precautions

 Consider the physical environment including any issues with muscles in the hand or
arm or with respect to vision.
 Remove or lower the clock in the room or be aware about whether the participant has
brought a wrist watch.

88
Scoring and Interpretation

There are a number of scoring systems used in the literature but no one scoring system shows
superior predictive validity. Much is gained by observation of the task, and scoring is
descriptive. The main aspects to consider are:

(i) correct spacing with even spaces between numbers and correct placement of
12,3,6, and 9
(ii) correct placement of hands (e.g.10 past 11) (Brodaty et al, 2002).

Clock phase is divided into quadrants, the number of digits in each quadrant is counted. If
a digit falls on the reference line, then it is counted in that quadrant. Each point for the
number and a point of one of correct representation for the hour and minute.

A prior criterion for evaluating clock drawings (Sunderland et al. 1989)Cut off score = 5 or
less indicates impairment.

(10 – 6) Drawing of clock face with number and circle generally intact

10 - Hands in correct position (i.e. Hours hand approaching 3 o'clock)

9 - Slight errors in placement of hands.

8 - More noticeable errors in placement of hour and minute hands.

7 - Placement of hands is significantly off course.

6 - Inappropriate use of clock hands (i.e. use of digital display or circling numbers despite
repeated instructions).

(5 - 1) Drawing of clock face with circle and numbers is NOT intact

5 - Crowding of numbers at one end of the clock or reversal of numbers. Hands may still be
present in some fashion.

4 - Further distortion of number sequence. Integrity of clock face is now gone (i.e. numbers
missing or placed outside of boundaries of the clock face).

89
3 - Numbers and clock face no longer obviously connected in the clock drawing. Hands are
not present.

2 - Drawing reveals some evidence of instructions being received but only vague
representation of a clock.

1 - Either no attempt or an uninterpretable effort is made.

RESULT

Table1 shows the Raw score obtained by examinee and its interpretation obtained by the
subject

Score Interpretation
10 Drawing of clock face with number and
circle generally intact. Hands in correct
position, no errors in placement of hands.

Since there are no errors in the drawing of clock without any difficulties and errors the
subject has scored 10 in Clock design Test.

DISCUSSION

The aim of the test was to assess the cognitive impairment and spatial dysfunction of the

participants using the clock drawing test. Name of the subject was PA. She is a 69-year-old

house wife. Subject has completed high school education. The subject was well groomed,

cooperative and articulated herself clearly, and she has no history of mental or physical

illness.

The subject has scored high on the clock drawing test, by drawing of

clock face with number and circle generally intact, Hands in correct position and no errors in

90
placement of hands. This might primarily indicate that the subject is not suffering from brain

disorders such as Constructional Apraxia, Dementia, Alzheimer’s and other severe

neurological conditions that influence proper cognitive functioning. Normal performance in

this test also reveals that the subjects visual spacial ability remains intact. Doing the Clock

drawing test also requires verbal understanding, memory and spatial coded knowledge in

addition to constructive skill. Since the subject produced clock design as instructed to her, we

can also assume that the subject might not have deficits in the above-mentioned domains as

well. The subject also successfully completed the task in less than two minutes. The subject

reported stress free non disturbed experimental session.

CONCLUSION: The subject showed absence of special dysfunction in the clock drawing
test.

REFERENCES

Sunderland, T., Hill, J.L., Mellow, A.M., Lawlor, B.A., Gundersheimer, J., Newhouse, P.A.,

& Grafman, J.H. (1989). Clock drawing in Alzheimer’s disease: a novel measure of

dementia severity. Journal of the American Geriatrics Society , 37, 725- 729.

Brodaty H, Pond D, Kemp NM, et al. (2002). The GPCOG: A new screening test for

dementia designed for general practice. Journal of the American Geriatrics Society,

50(3), 530-534.

Grieve, J. (2000). Neuropsychology for occupational therapists: Assessment of perception

and cognition (2nd ed.). Oxford: Blackwell Science.

Mather, N., & Wendling, B. J. (2005). Linking cognitive assessment results to academic

interventions for students with learning disabilities. In D. P. Flanagan & P. L.

91
 Harrison (Eds.), Contemporary intellectual assessment: Theories, tests, and issues

(2nd ed., pp. 269–294). New York: Guilford Press.

Sattler, J. M., & Hoge, R. D. (2006). Assessment of children: Behavioral, social, and clinical

foundations (5th ed.). San Diego: Jerome M. Sattler.

Pal A, Biswas A, Pandit A.(2016). Study of visuospatial skill in patients with dementia. Ann

Indian Acad Neurol;19(1):83–88. doi:10.4103/0972-2327.168636

Russell, C., Deidda, C., Malhotra, P., Crinion, J. T., Merola, S., & Husain, M. (2010). A

deficit of spatial remapping in constructional apraxia after right-hemisphere stroke.

Brain : a journal of neurology, 133(Pt 4), 1239–1251.

https://doi.org/10.1093/brain/awq052

Guérin F, Ska B, Belleville S (August 1999). "Cognitive processing of drawing abilities".

Brain Cogn. 40 (3): 464–78. doi:10.1006/brcg.1999.1079. PMID 10415132.

Caminiti R, Chafee MV, Battaglia-Mayer A, Averbeck BB, Crowe DA, Georgopoulos AP

( 2010). "Understanding the parietal lobe syndrome from a neurophysiological and

evolutionary perspective". Eur. J. Neurosci. 31 (12): 2320–40

92