Relation between the clock drawing test (CDT) and structural changes of brain in dementia

https://doi.org/10.1016/j.archger.2008.01.010Get rights and content

Abstract

The CDT is a useful screening instrument for assessing cognition. The aim of this study is to identify which structural change of the brain is related with the CDT performance. Eighty-four patients with memory impairment were enrolled. The Korean versions of the mini-mental state examination (K-MMSE) and the modified mini-mental state (3MS) test, and the Seoul Neuropsychological Screening Battery (SNSB) were given to every subject. Four CDT scoring methods were used. The cerebral white matter hyperintensity (WMH), cortical atrophy (CA), ventricular enlargement (VE), and medial temporal lobe atrophy (MTA) were rated by two neurologists who were kept “blind” to the clinical information. The cognitive and executive functions were significantly correlated with the CDT performance. The degree of WMH and MTA showed an inverse relation with the CDT performance. The periventricular WMH (PVH) contributed more to impairment of CDT, than that of the deep WMH (DWMH). This study suggests that a combination of executive dysfunction via the frontal-subcortical disruption due to the PVH and memory impairment due to the MTA might be responsible for further worsening on the CDT.

Introduction

CDT has been regarded as a simple and useful screening tool for determining cognitive functioning in neurodegenerative disorders (Libon et al., 1996, Richardson and Glass, 2002, Cahn-Weiner et al., 2003, Lin et al., 2003). The diverse cognitive skills that are needed for the CDT operate in the different brain regions; these skills are verbal understanding, memory, spatially coded knowledge, abstract thinking, planning and visuo-constructive functions. The CDT also reflects deficits in the executive function, which are often overlooked by routine cognitive evaluations (Kitabayashi et al., 2001, Ino et al., 2003). However, little is known about the relation between the CDT and such structural cerebral changes as WMH or CA in dementia patients.

We expect that performance on the CDT may be influenced by frontal-subcortical circuits that have a role for the executive function. The purpose of the present study is to identify structural cerebral changes that might contribute to the results of the CDT taken by patients diagnosed with dementia.

Section snippets

Participants

Eighty-four patients who were diagnosed with dementia were enrolled for this retrospective study. They attended the outpatient memory clinic of the Neurology Department at Chungnam University Hospital from January 2005 to April 2006 due to their cognitive impairment. Brain magnetic resonance imaging (MRI), laboratory studies and cognitive assessments, including the CDT, were given to all patients. Alzheimer's disease (AD), (n = 41) was diagnosed by the National Institute of Neurological and

Sample characteristics

Table 1 shows the baseline characteristics of the study population. The mean age of the total sample was 69.4 years (range: 42–82 years). The mean scores of the MMSE and 3MS tests were 21.6 and 67.2, respectively.

Neuropsychological tests

The results obtained by the methods of Wolf-Klein et al. (1989) and of Manos and Wu (1994) had positive correlations with the MMSE/3MS tests. In contrast, the methods of Watson et al. (1993) and of Shulman et al. (1993) gave negative correlations with the MMSE/3MS tests. Performance on

Discussion

In terms of the neuropsychological aspects, performance on the CDT showed a significant relation with the overall level of cognition and the executive function. This is consistent with the results of prior studies that proved that the CDT was sensitive to executive control, regardless of the underlying disease (Libon et al., 1996, Royall et al., 1998, Royall et al., 1999). Although one study has reported low CDT scores for patients with normal MMSE scores (Juby et al., 2002), the overall

References (30)

  • M.M. Esiri et al.

    Cerebrovascular disease and threshold for dementia in the early stages of Alzheimer's disease

    Lancet

    (1999)
  • T. Ino et al.

    Parieto-frontal networks for clock drawing revealed with fMRI

    Neurosci. Res.

    (2003)
  • D.J. Libon et al.

    Further analyses of clock drawings among demented and nondemented older subjects

    Arch. Clin. Neuropsychol.

    (1996)
  • D.A. Cahn-Weiner et al.

    Discrimination of dementia with Lewy bodies from Alzheimer disease and Parkinson disease using the clock drawing test

    Cogn. Behav. Neurol.

    (2003)
  • J.C. De Groot et al.

    Cerebral white matter lesions and cognitive function: the Rotterdam Scan Study

    Ann. Neurol.

    (2000)
  • F.E. De Leeuw et al.

    White matter lesions and hippocampal atrophy in Alzheimer's disease

    Neurology

    (2004)
  • F. Fazekas et al.

    MR signal abnormalities at 1.5 T in Alzeheimer's dementia and normal aging

    Am. J. Roentgenol.

    (1987)
  • H. Forstl et al.

    Neuropathological basis for drawing disability (constructional apraxia) in Alzheimer's disease

    Psychol. Med.

    (1993)
  • T. Jobe et al.

    The Executive Interview (EXIT) and Cerebral Perfusion SPECT Imaging in the Assessment of the Frontal Lobes

    (1996)
  • A. Juby et al.

    The value of clock drawing in identifying executive cognitive dysfunction in people with a normal mini-mental state examination score

    Can. Med. Assoc. J.

    (2002)
  • Y.W. Kang et al.

    A validity study on the Korean mini-mental state examination (K-MMSE) in dementia patients

    J. Korean Neurol. Assoc.

    (1997)
  • Y. Kitabayashi et al.

    Qualitative analyses of clock drawings in Alzheimer's disease and vascular dementia

    Psychiatry Clin. Neurosci.

    (2001)
  • E.S. Korf et al.

    Medial temporal lobe atrophy on MRI predicts dementia in patients with mild cognitive impairment

    Neurology

    (2004)
  • K.N. Lin et al.

    The three-item clock-drawing test: a simplified screening test for Alzheimer's disease

    Eur. Neurol.

    (2003)
  • T.A. Manolio et al.

    Magnetic resonance abnormalities and cardiovascular disease in older adults: The Cardiovascular Health Study

    Stroke

    (1994)
  • Cited by (28)

    • Left lateral parietal rTMS improves cognition and modulates resting brain connectivity in patients with Alzheimer's disease: Possible role of BDNF and oxidative stress

      2021, Neurobiology of Learning and Memory
      Citation Excerpt :

      Nevertheless, our findings showing a significant alteration in clock drawing specific brain regions (decreased fusiform gyrus, precuneus, and increased right frontal opercular area activity), are generally in line with previous studies showing significant functional differences between normal individuals and AD patients (Kang et al., 2019; Leyhe et al., 2009; Talwar et al., 2019). With this, several structural, metabolic and functional neuroimaging studies have suggested that impaired Clock Drawing Test performance scores are associated with altered activity of frontal and parietal regions in dementia (Brugnolo et al., 2010; Kim et al., 2009; Shon et al., 2013). Conversely, fusiform, and right frontal (opercular) Blood Oxygen Level Dependent (BOLD) activity has been recently reported to be decreased during the Clock Drawing Test in healthy individuals (Talwar et al., 2019).

    • The Relationship between Plasma Al Levels and Multi-domain Cognitive Performance among In-service Aluminum-exposed Workers at the SH Aluminum Factory in China: A Cross-sectional Study

      2020, NeuroToxicology
      Citation Excerpt :

      However, the impairments in the latter functions may also occur in patients with the early stage of AD (Schramm et al., 2002; Ahmed et al., 2016). Hence, the CDT, which has been mainly used to reflect executive/visuospatial functions (Kim et al., 2009; Mitchell and Malladi, 2010a), was combined with the visuospatial assessment in MMSE to bridge this gap. The cognitive status of individuals with or without impairments was determined based on the cut-off points for the neurobehavioral scales.

    • Cortical signature of clock drawing performance in Alzheimer's disease and mild cognitive impairment

      2017, Journal of Psychiatric Research
      Citation Excerpt :

      It is fast to administer and well accepted among elderly patients (Seidl et al., 2012; Thomann et al., 2008b). Given that CDT necessitates a tight link between selective and sustained attention, verbal working memory, numerical knowledge, visuospatial abilities, motor execution, and executive function (Mendez et al., 1992; Shulman, 2000), previous MRI studies indicated that CDT performance is not attributable to few specific brain structures but rather to structural and functional alterations in multiple areas comprising frontal, temporal and parietal cortical fields, the hippocampus, the thalamus, the caudate nucleus, the putamen, and the cerebellum (Cahn-Weiner et al., 1999; Ino et al., 2003; Kim et al., 2009; Matsuoka et al., 2011; Nagahama et al., 2005; Thomann et al., 2008b). What we know about CDT impairment in patients with AD and subjects with mild cognitive impairment (MCI) largely stems from voxel-based morphometry (VBM) studies that analyzed alterations of cortical volume underlying CDT performance.

    View all citing articles on Scopus
    View full text