Impaired Clock Drawing Test Research Articles

Relationship between comprehensive geriatric assessment and amyloid PET in older persons with MCI

BackgroundThe association between amyloid deposition and cognitive, behavioral and physical performance in mild cognitive impairment (MCI) due to Alzheimer’s disease (AD) has been poorly investigated, especially in older persons.MethodsWe studied the in vivo correlation between the amyloid deposition at Positron Emission Tomography (amyloid-PET) and the presence of memory loss, reduced executive function, neuropsychiatric symptoms and physical performance in older persons with MCI. Amyloid-PET was performed with 18F-flutemetamol and quantitatively analyzed.ResultsWe evaluated 48 subjects, 21 men and 27 women. We performed in each patient a comprehensive geriatric assessment (CGA) including Mini Mental State Examination (MMSE), Clock Drawing Test (CDT), Activity Daily Living (ADL), Instrumental Activity of Daily Living (IADL), Neuropsychiatric inventory (NPI) questionnaire, 15 Geriatric Depression Scale (GDS), Short Physical Performance Battery (SPPB) and Hand Grip strength. Then, each patient underwent amyloid-PET. Mean age of the enrolled subjects was 74.6 ± 7.8 years. All of these subjects showed preserved cognitive function at MMSE > 24, while 29 of 48 subjects (61.0%) had altered CDT.Mean NPI score was 6.9 ± 5.9. The mean value of SPPB score was 9.0 ± 2.6, while the average muscle strength of the upper extremities measured by hand grip was 25.6 ± 7.7 Kg. CT/MRI images showed cortical atrophic changes in 26 of the 48 examined subjects (54.0%), while cerebrovascular modifications were present in 31 subjects (64.5%). Pathological burden of amyloid deposits was detected in 25 of 48 (52.0%) patients with a mean value of global z-score of 2.8 (subjects defined as MCI due to AD).After stratifying subjects in subclasses of clinical alterations, more probability of pathological amyloid deposition was found in subjects with impaired CDT and higher NPI score (O.R. = 3.45 [1.01–11.2], p = 0.04), with both impaired CDT and low physical performance (O.R. = 5.80 [1.04–32.2], p = 0.04), with altered CDT and high NPI score (O.R. = 7.98 [1.38–46.0], p = 0.02), and finally in those subjects with altered CDT, high NPI and low physical performance (O.R. = 5.80 [1.05–32.2], p = 0.04).ConclusionOur findings support the recent hypothesis that amyloid deposition could be associated with multiple cerebral dysfunction, mainly affecting executive, behavioral and motor abilities.

The relevance of hippocampal subfield integrity and clock drawing test performance for the diagnosis of Alzheimer’s disease and mild cognitive impairment

Objectives: The clock drawing test (CDT) is one of the worldwide most used screening tests for Alzheimer’s disease (AD). MRI studies have identified temporo-parietal regions being involved in CDT impairment. However, the contributions of specific hippocampal subfields and adjacent extrahippocampal structures to CDT performance in AD and mild cognitive impairment (MCI) have not been investigated so far. It is unclear whether morphological alterations or CDT score, or a combination of both, are able to predict AD.Methods: 38 AD patients, 38 MCI individuals and 31 healthy controls underwent neuropsychological assessment and MRI at 3 Tesla. FreeSurfer 5.3 was used to perform hippocampal parcellation. We used a collection of statistical methods to better understand the relationship between CDT and hippocampal formation. We also tested the clinical feasibility of this relationship when predicting AD.Results: Impaired CDT performance in AD was associated with widespread atrophy of the cornu ammonis, presubiculum, and subiculum, whereas MCI subjects showed CDT-related alterations of the CA4-dentate gyrus and subiculum. CDT correlates in AD and MCI showed regional and quantitative overlap. Importantly, CDT score was the best predictor of AD.Conclusions: Our findings lend support for an involvement of different hippocampal subfields in impaired CDT performance in AD and MCI. CDT seems to be more efficient than subfield imaging for predicting AD.

Clock drawing test in a space-occupying process.

We read with great interest the article of van Munster et al on a dural fistula presenting as a treatable cause of cognitive impairment.1 The authors demonstrated a markedly impaired clock drawing test (CDT) before treatment, which completely normalized after therapy. By presenting a case vignette, we wish to emphasize that an impaired CDT—especially in a younger individual—can be an alarming sign to prompt further examination. A 43-year-old right-handed teacher noted difficulty in drawing graphs of functional equations during lessons. The complete clinical neurological examination including confrontation testing of visual fields was unremarkable. The mini-mental state test revealed a score of 29 of 30 with 1 point deducted for short-term recall. The CDT, however, showed marked impairment (Figure 1A). A subsequent magnetic resonance imaging demonstrated a space-occupying lesion in the left parietal lobe (Figure 1B), which was histologically a high-grade glioma at surgery. Figure 1. A, Impaired clock drawing test in a 43-year-old woman, which prompted magnetic resonance imaging. B, Magnetic resonance imaging with gadolinium reveals a space-occupying process in the left parietal lobe. The CDT has achieved widespread clinical use as a cognitive screening instrument.2 It complements the Mini-Mental State Examination and serves as an efficient screen for early detection of dementia and in monitoring cognitive function.2,3 In particular, the CDT evaluates organization and planning,4 executive function,2 and visual perception. In our patient, impaired visual perception due to the left parietal lobe lesion was likely responsible for the marked CDT finding. This case reminded us that in the field of neurohospitalist medicine, an impaired CDT can be a prominent and isolated clinical finding in a left hemisphere space-occupying lesion. As demonstrated by van Munster et al, an impaired CDT can return to normal after proper treatment.1

Poster #T193 SEX-DIFFERENCES IN THE RELATIONSHIP BETWEEN CANNABIS USE AND RISK OF ADMISSION IN YOUNG SUBJECTS WITH AN EARLY PSYCHOSIS: A 1-YEAR FOLLOW-UP STUDY

The clock drawing test (CDT) is a widely used dementia screening instrument that assesses executive and visuospatial abilities; studies in patients with Alzheimer's disease (AD) suggest frontoposterior networks to be involved in clock drawing. Clock drawing errors are also often observed in dementia with Lewy bodies (DLB), but the functional neuroanatomical substrate of impaired clock drawing has not been firmly established in this disorder. The present study was designed to provide initial evidence for brain metabolic alterations associated with CDT performance in DLB. Twenty-one patients with DLB were enrolled. CDT ratings were correlated with the regional cerebral metabolic rate of glucose (rCMRglc) measured by 18F-fluoro-2-deoxy-glucose positron emission tomography (18F-FDG PET) in the statistical parametric mapping software package SPM5, controlling for overall cognitive impairment as measured by the Mini-Mental-State Examination (MMSE) score. There was a significant negative association between test scores and rCMRglc in a left-hemispheric posterofrontal network including the temporoparietal and dorsal pre-motor cortices and the precuneus. The present study provides evidence for a direct association between frontoparietal dysfunction and impaired CDT performance in DLB. These findings also suggest that the CDT is an appropriate screening instrument for this disorder and that metabolic dysfunction, and therefore disease severity, is mirrored by performance on the test.

Subcortical morphological correlates of impaired clock drawing performance

The objective of this study was to investigate the associations between clock drawing test (CDT) performance and subcortical brain morphology. Fifty-four participants (21 patients with Alzheimer's disease, 23 with mild cognitive impairment and 10 healthy controls) underwent neuropsychological assessment and high-resolution magnetic resonance imaging at 3T. CDT performance was related to volume and shape measurements of amygdala, caudate nucleus, hippocampus, nucleus accumbens, pallidum, putamen, and thalamus, respectively. Impaired CDT performance was correlated with alterations predominantly in the hippocampus bilaterally and in the right globus pallidus. These associations referred to regionally specific morphometric alterations rather than to global atrophy of the respective structures. Our findings support an involvement of subcortical brain regions in CDT performance.

Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study.

While the association between benzodiazepines (BZD) and single fall is long-known, the association between BZD and recurrent falls has been few studied. The aims of this study were 1) to examine whether BZD were associated with recurrent falls while taking into account the effect of potential confounders, and 2) to determine whether there was an interaction in terms of risk of falls between BZD and balance impairment in a community-dwelling population-based adults aged 65 and older. Cross-sectional. Three health centers in North-East of France. 7643 community-dwelling volunteers aged 65 and older. The use of BZD, the Mini Mental State Examination (MMSE) score, the Clock Drawing Test (CDT), the One Leg Balance (OLB) test, the Five Times Sit-To-Stand test (FTSS), and a history of falls were recorded. Subjects were separated into 4 groups based on the number of falls: 0, 1, 2 and ≥ 3 falls. Among the 1456 (19.2%) fallers, 994 (13.0%) were single fallers and 462 (6.1%) were recurrent fallers (i.e., > 2 falls). The number of falls increased significantly with age (Incident Rate Ratio (IRR)=1.04, P < 0.001), female gender (IRR=2.24, P < 0.001), the use of benzodiazepine (IRR=1.65 P < 0.001) and especially while subjects used bromazepam (IRR=1.44, P=0.006), clobazam (IRR=3.01, P=0.014) and prazepam (IRR=2.29, P < 0.001). A low MMSE score (IRR=0.96, P < 0.001), an impaired CDT (IRR=0.91, P < 0.001), and a bad performance at OLB and FTSS (respectively IRR=1.85, P < 0.001 and IRR=1.26, P < 0.001) were related to the recurrence of falls. After adjustment only the advance in age (IRR=1.02, P < 0.001), female gender (IRR=2.15, P < 0.001), clobazam (IRR=2.54, P=0.04), prazepam (IRR=1.63, P=0.03) and OLB (IRR=1.55, P < 0.001) were still significantly related to the number of falls. The current study shows that the age, the female gender, the use of clobazam or prazepam and a low score at OLB are related to the recurrence of falls.

Metabolic alterations associated with impaired clock drawing in Lewy body dementia

The clock drawing test (CDT) is a widely used dementia screening instrument that assesses executive and visuospatial abilities; studies in patients with Alzheimer's disease (AD) suggest frontoposterior networks to be involved in clock drawing. Clock drawing errors are also often observed in dementia with Lewy bodies (DLB), but the functional neuroanatomical substrate of impaired clock drawing has not been firmly established in this disorder. The present study was designed to provide initial evidence for brain metabolic alterations associated with CDT performance in DLB. Twenty-one patients with DLB were enrolled. CDT ratings were correlated with the regional cerebral metabolic rate of glucose (rCMRglc) measured by 18F-fluoro-2-deoxy-glucose positron emission tomography ( 18F-FDG PET) in the statistical parametric mapping software package SPM5, controlling for overall cognitive impairment as measured by the Mini-Mental-State Examination (MMSE) score. There was a significant negative association between test scores and rCMRglc in a left-hemispheric posterofrontal network including the temporoparietal and dorsal pre-motor cortices and the precuneus. The present study provides evidence for a direct association between frontoparietal dysfunction and impaired CDT performance in DLB. These findings also suggest that the CDT is an appropriate screening instrument for this disorder and that metabolic dysfunction, and therefore disease severity, is mirrored by performance on the test.

Clock drawing and rehabilitation outcome in hip fracture patients

Purpose. To assess the relationship between the Clock Drawing Test (CDT) and rehabilitation outcome in hip fracture patients within normal range of the Mini Mental State Examination (MMSE).Methods. This retrospective study was performed in a post-acute geriatric rehabilitation centre. One hundred and forty-two patients with proximal hip fracture admitted from January 2006 to June 2008 whose MMSE scores was within normal range (>23) were enrolled in the study. The patients were divided into two groups according to CDT performance (impaired versus intact). The differences between the two groups in relation to age, gender, education level, living arrangement, pre fracture functional level, fracture type, and outcome measurements [Functional Independent Measure (FIM), motor FIM, Rate of in-hospital Improvement (RI) in FIM and motor FIM, and Length of Stay (LOS)] were assessed.Results. Discharge FIM score and motor FIM scores were significantly lower for the impaired CDT group (89 ± 13.7 vs. 94.9 ± 11.6, p = 0.007; 61.6 ± 11.1 vs. 65.7 ± 9.6, p = 0.022 respectively); LOS was significantly longer (28.2 ± 7.9 vs. 25.3 ± 8.5, p = 0.033) and rates of improvement in FIM and motor FIM were significantly slower (0.62 ± 0.35 vs. 0.77 ± 0.45, p = 0.036; 0.61 ± 0.34 vs. 0.75 ± 0.42, p = 0.033, respectively). Nevertheless, FIM and motor FIM scores changes were similar in both CDT groups. Following adjustment for age, LOS of patients with impaired CDT was significantly longer (p = .027).Conclusions. The CDT may assist the multidisciplinary team in identifying hip fracture patients whose MMSE scores are within the normal range, but yet need a longer training period to extract their rehabilitation potential.

P3-151: White matter hyperintensities within cholinergic pathways in Alzheimer's disease affecting the clock drawing test performance

Cerebral white matter hyperintensities (WMH) are common findings on MRI in elderly people. Two possible mechanisms have been suggested: 1) by disruption of corticocortical association fibers or fronto-subcortical neuronal networks; 2) interference with cholinergic projecting pathway. The purpose of this study is to evaluate how WMH can affect on the Clock Drawing Test in Alzheimer disease (AD). One hundred twenty seven patients with AD were enrolled for this study. Subjects met the National Institute of Neurological Communicative Disorders and Stroke-Alzheimer Disease and Related Disorders Association (NINCDS-ADRDA) research criteria for possible or probable AD. All subjects were taken MRI to measure the severity of WMH based on visual inspection of T2-weighted and proton-density MRI. Subjects underwent standardized neuropsychological testing, including Korean versions of the Mini-Mental State Exam (MMSE) and the modified MMSE (3MS) to assess cognitive domains of interest (attention, memory, executive function) as well as general level of cognition. Clock Drawing Test (CDT) was given to all patients to analyze the level of performance and error-types. Manos scoring protocol was adopted for the evaluation of CDT results. Cognitive measures and the CDT were assessed independently by a neuropsychologist and a neurologist who were not aware of clinical information. The Age-Related White Matter Changes (ARWMC) rating scale of the European Task Force was used as a general measure of WMH severity. WMH involved in cholinergic pathways were measured by the Cholinergic Pathways Hyperintensities Scale (CHIPS). Performance of the CDT as well as overall level of cognition showed significant relation with the WMC severity. Temporal WMH in ARWMC had stronger relationship with the CDT performance than other areas. WMH of the posterior corona radiata in CHIPS showed significant correlation with the CDT performance. Interference in the cholinergic projecting pathway as well as disruption of cortico-subcortical neural networks by WMH may contribute to the impaired CDT performance in AD.

Cerebral Substrates Related to Impaired Performance in the Clock-Drawing Test in Dementia with Lewy Bodies

Aims: To identify the neural correlates of impaired performance in the clock-drawing test (CDT) in patients with dementia with Lewy bodies (DLB). Methods: Cerebral blood flow was measured by single photon emission computed tomography in patients with clinically diagnosed DLB, and was compared between impaired CDT (n = 30) and normal CDT (n = 30) subgroups. Results: DLB patients with impaired CDT performance showed significantly lower cerebral blood flow in the bilateral frontal eye fields, supplementary eye fields, right posterior putamen and the right ventrolateral part of the thalamus relative to the normal CDT subgroup. Performance in other visuospatial/attentional tasks (trail making test part A, copying a cube, semantic fluency, and block design) was also poorer in the impaired CDT group than the normal CDT group. Conclusions: This study indicates that impaired performances on the CDT and some visuospatial/attentional tasks by DLB patients are closely related to dysfunctions of the frontal-subcortical network relevant to control of visuospatial attention and arousal, involving the frontal eye fields, supplementary eye fields and the thalamus. Our findings provide evidence that cognitive performance in DLB reflects the pathological involvement of both cortical and subcortical regions, and suggest that the neurophysiological basis underlying impaired CDT in DLB may be different from that in Alzheimer disease.

Neural Correlates of Impaired Performance on the Clock Drawing Test in Alzheimer’s Disease

To identify the neural correlates for impaired performance on the clock drawing test (CDT) in patients with Alzheimer’s disease (AD), we examined the relationship between the CDT performances and the regional cerebral blood flow (rCBF) in 100 AD patients. The patients were equally divided into a mildly impaired CDT group, a severely impaired CDT group, and two normal CDT groups, with age and dementia severity matched. Between-group comparisons revealed that rCBF reduction in the posterolateral region of the left temporal lobe was consistently associated with mild to severe impairment of the CDT in AD. Correlation analysis also showed that the rCBF in the left posterolateral temporal cortex was linearly correlated with CDT performance. The CDT scores in AD were significantly improved for the copy condition relative to the drawing-to-command condition. These findings suggest that CDT performance has a close relationship with the left posterior temporal function, and that semantic memory deficit may at least partly contribute to impaired CDT performance in AD.