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Effects of education, literacy, and dementia on the Clock Drawing Test performance

Published online by Cambridge University Press:  20 October 2010

HOYOUNG KIM
Affiliation:
Department of Psychology, Seoul National University, Seoul, Korea
JEANYUNG CHEY*
Affiliation:
Department of Psychology, Seoul National University, Seoul, Korea Interdisciplinary Program for Brain Sciences, Seoul National University, Seoul, Korea
*
*Correspondence and reprint requests to: Jeanyung Chey, Department of Psychology, Seoul National University, Gwanak-ro 599, Gwanak-gu, Seoul, 151-742, South Korea. E-mail: jychey@snu.ac.kr

Abstract

The Clock Drawing Test (CDT) has been recognized as an effective tool for dementia detection. This study investigated the clock drawing performance of 240 non-demented elderly Korean people with a wide-range of educational levels and 28 patients with mild dementia of the Alzheimer’s type (DAT). We examined the effects of demographic factors, including education, and established norms for the elderly population. We found that the educational attainment and literacy status of older people influenced performance on the CDT significantly (p < .001). Furthermore, qualitative error analysis revealed that normal participants with low educational background committed errors similar to errors of the DAT patients. The DAT patients performed significantly worse than the non-demented participants in the CDT Total score (p < .001). However, the CDT has better criterion validity in participants with more than 6 years of education. In conclusion, the CDT performance in older people who are either illiterate or with 6 or less years of education should be interpreted with caution. Conceptual errors in the CDT can be the result of not only dementia but also lack of education. (JINS, 2010, 16, 1138–1146.)

Type
Research Articles
Copyright
Copyright © The International Neuropsychological Society 2010

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References

REFERENCES

Ainslie, N.K., & Murden, R.A. (1993). Effect of education on the Clock-Drawing dementia screen in non-demented elderly persons. Journal of the American Geriatric Society, 41, 249252.CrossRefGoogle ScholarPubMed
Chey, J. (1998). Korean-Dementia Rating Scale. Seoul: Hakjisa.Google Scholar
Chey, J. (2007). Elderly Memory Disorder Scale. Seoul: Hakjisa.Google Scholar
Chey, J., Na, D.R., Park, S., Park, E., & Lee, S. (1999). Effects of education in dementia assessment: Evidence from standardizing the Korean-Dementia Rating Scale. The Clinical Neuropsychologist, 13, 293302.CrossRefGoogle ScholarPubMed
Chey, J., Na, D.G., Tae, W.S., Ryoo, J.W., & Hong, S.B. (2006). Medial temporal lobe volume of nondemented elderly individuals with poor cognitive functions. Neurobiology of Aging, 27, 12691279.CrossRefGoogle ScholarPubMed
Chiu, Y.C., Li, C.L., Lin, K.N., Chiu, Y.F., & Liu, H.C. (2008). Sensitivity and specificity of the Clock Drawing Test, incorporating Rouleau scoring system, as a screening instrument for questionable and mild dementia: Scale development. International Journal of Nursing Studies, 45, 7584.CrossRefGoogle ScholarPubMed
Christensen, K.J., Multhaup, K.S., Nordstroal, S., & Voss, K. (1991). A cognitive battery for dementia development and measurement characteristics. Psychological Assessment, 3, 168174.CrossRefGoogle Scholar
Critchley, M. (1953). The parietal lobes. New York: Hafner Press.Google Scholar
Death, J., Douglas, A., & Kennedy, R.A. (1993). Comparison of clock drawing with Mini-Mental Status Examination as a screening test in elderly acute hospital admissions. Postgraduate Medical Journal, 69, 696700.CrossRefGoogle ScholarPubMed
Freedman, M., Leach, L., Kaplan, E., Delis, D., Shulman, K., & Winocur, G. (1994). Clock drawing: A neuropsychological analysis. New York: Oxford University Press.Google Scholar
Hubbard, E.J., Santini, V., Blankevoort, C.G., Volkers, K.M., Barrup, M.S., Byerly, L., et al. . (2008). Clock drawing performance in cognitively normal elderly. Achives of Clinical Neuropsychology, 23, 295327.CrossRefGoogle ScholarPubMed
Kitabayashi, Y., Ueda, H., Narumoto, J., Nakamura, K., Kita, H., & Fukui, K. (2001). Qualitative analysis of clock drawings in Alzheimer’s disease and vascular dementia. Psychiatry and Clinical Neurosciences, 55, 485491.CrossRefGoogle ScholarPubMed
Koffler, S.L. (1980). A comparison of approaches for setting proficiency standards. Journal of Educational Measurement, 17, 167178.CrossRefGoogle Scholar
Korea Ministry of Health and Welfare. (2007). Health and welfare services 2006: Annual report. Kwacheon: Ministry of Health and Welfare.Google Scholar
Kwon, Y.C., & Park, J.H. (1989). A standardization study of the Korean Mini-Mental State Examination (MMSE-K) for the elderly population. Journal of the Korean Neuropsychiatric Association, 28, 125135.Google Scholar
Lam, L.W.C., Chiu, H.F.K., Ng, K.O., Chan, C., Chan, W.F., Li, S.W., et al. . (1998). Clock face drawing, reading, and setting tests in screening of dementia in Chinese elderly adults. Journal of Gerontology, 53B, 353357.CrossRefGoogle Scholar
Lee, N.Y. (2001). Interview for the preclinical dementia patients. Unpublished master’s thesis, Sungshin Women’s University, Seoul, Korea.Google Scholar
Lessig, M.C., Scanlan, J.M., Nazemi, H., & Borson, S. (2008). Time that tells: Critical clock-drawing errors for dementia screening. International Psychogeriatrics, 20, 459470.CrossRefGoogle ScholarPubMed
Leung, J.C.W., Lui, V.W.C., & Lam, L.C.W. (2005). Screening for early Alzheimer’s disease in elderly Chinese patients using the Chinese Clock Drawing Test. Hong Kong Journal of Psychiatry, 15, 1417.Google Scholar
Lin, K.N., Wang, P.N., Chen, C., Chiu, Y.H., Kuo, C.C., Chuang, Y.Y., et al. . (2003). The three-item clock-drawing test: A simplified screening test for Alzheimer’s disease. European Neurology, 49, 5358.CrossRefGoogle Scholar
Luria, A. (1980). Higher cortical functions in man (2nd ed.). New York: Basic Books.CrossRefGoogle Scholar
Manly, J.J., Jacobs, D.M., Sano, M., Bell, K., Merchant, C.A., Small, S.A., et al. . (1999). Effects of literacy on neuropsychological test performance in nondemented, education-matched elders. Journal of the International Neuropsychological Society, 5, 191202.CrossRefGoogle ScholarPubMed
Marcopulos, B.A., McLain, C.A., & Giuliano, A.J. (1997). Cognitive impairment or inadequate norms? A study of healthy, rural, older adults with limited education. The Clinical Neuropsychologist, 11, 111131.CrossRefGoogle Scholar
Mattis, S. (1988). Dementia Rating Scale (DRS): Professional manual. Odessa, FL: Psychological Assessment Resources.Google Scholar
McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D., & Stadlan, E.M. (1984). Clinical diagnosis of Alzheimer’s disease: Report of the NINCDS-ADRDA work group, Department of health and human services task force on Alzheimer’s disease. Neurology, 34, 939944.CrossRefGoogle ScholarPubMed
Mendez, M.F., Ala, T., & Underwood, K. (1992). Development of scoring criteria for the clock drawing task in Alzheimer’s disease. Journal of American Geriatric Society, 40, 10951099.CrossRefGoogle ScholarPubMed
Milberg, W.P., Hebben, N., & Kaplan, E. (1996). The Boston process approach to neuropsychological assessment. In Grant, I. & Adams, K.M. (Eds.), Neuropsychological assessment of neuropsychiatric disorders (2nd ed.). New York: Oxford University Press.Google Scholar
Moon, H.S., & Chey, J. (2004). Literacy and neuropsychological functions in the older Korean adults. Journal of Korean Geriatric Psychiatry, 8, 113120.Google Scholar
Nitrini, R., Caramelli, P., Herrera, E., Porto, C.S., Charchat-Fichman, H., Carthery, M.T., et al. . (2004). Performance of illiterate and literate nondemented elderly participants in two tests of long-term memory. Journal of the International Neuropsychological Society, 10, 634638.CrossRefGoogle Scholar
Pinto, E., & Peters, R. (2009). Literature review of the clock drawing test as a tool for cognitive screening. Dementia and Geriatric Cognitive Disorders, 27, 201213.CrossRefGoogle ScholarPubMed
Ratcliff, G., Dodge, H., Birzescu, M., & Ganguli, M. (2003). Tracking cognitive functioning over ten years of followup of a rural elderly community population. Applied Neuropsychology, 10, 7688.CrossRefGoogle Scholar
Reisberg, B., Ferris, S.H., De Leon, M.J., & Crook, T. (1982). The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 139, 11361139.Google ScholarPubMed
Rosselli, M., & Ardila, A. (2003). The impact of culture and education on non-verbal neuropsychological measurements: A critical review. Brain and Cognition, 52, 326333.CrossRefGoogle ScholarPubMed
Rouleau, I., Salmon, D.P., & Butters, N. (1996). Longitudinal analysis of clock drawing in Alzheimer’s disease patients. Brain and Cognition, 31, 1734.CrossRefGoogle ScholarPubMed
Rouleau, I., Salmon, D.P., Butters, N., Kennedy, C., & McGuire, K. (1992). Quantitative and qualitative analysis of clock drawings in Alzheimer’s and Huntington’s disease. Brain and Cognition, 18, 7087.CrossRefGoogle ScholarPubMed
Sahadevan, S., Lim, J.P.P., Tan, N.J.L., & Chan, S.P. (2002). Psychometric identification of early Alzheimer disease in an elderly Chinese population with differing educational levels. Alzheimer Disease and Associated Disorders, 16, 6572.CrossRefGoogle Scholar
Sano, M., Devanand, D.P., Richards, M., Miller, L.W., Marder, K., Bell, K., et al. . (1995). A standardized technique for establishing onset and duration of symptoms of Alzheimer’s disease. Archives of Neurology, 52, 961966.CrossRefGoogle ScholarPubMed
Shulman, K.I. (2000). Clock drawing: Is it the ideal cognitive screening test? International Journal of Geriatric Psychiatry, 15, 548561.3.0.CO;2-U>CrossRefGoogle ScholarPubMed
Shulman, K.I., Shedletsky, R., & Silver, I.L. (1986). The challenge of time: Clock- drawing and cognitive function in elderly. International Journal of Geriatric Psychiatry, 1, 135140.CrossRefGoogle Scholar
Todd, M.E., Dammers, P.M., Adams, S.G. Jr, Todd, H.M., & Morrison, M. (1995). An examination of a proposed scoring procedure for clock drawing test: Reliability and predictive validity of the clock scoring system (CSS). American Journal of Alzheimer’s Disease and Other Dementias, 10, 2226.CrossRefGoogle Scholar
Tuokko, H., Hadjistavropoulos, T., Miller, J.A., & Beattie, B.L. (1992). The clock test: A sensitive measure to differentiate normal elderly from those with Alzheimer’s disease. Journal of American Geriatric Society, 40, 579584.CrossRefGoogle Scholar
Von Gunten, A., Ostos-Wiechetek, M., Brull, J., Vaudaux-Pisquem, I., Cattin, S., & Duc, R. (2008). Clock-Drawing Test performance in the normal elderly and its dependence on age and education. European Neurology, 60, 7378.CrossRefGoogle ScholarPubMed
Watson, Y.I., Alfken, C.L., & Birge, S.J. (1993). Clock completion: An objective screening test for dementia. Journal of American Geriatric Society, 40, 579584.Google Scholar
Wolf-Klein, G.P., Silverstone, F.A., Levy, A.P., & Brod, M. (1989). Screening for Alzheimer’s disease by clock drawing. Journal of American Geriatric Society, 37, 730734.CrossRefGoogle ScholarPubMed
Yamamoto, S., Mogi, N., Umegaki, H., Suzuki, Y., Ando, F., Shimokata, H., et al. . (2004). The clock drawing tests as a valid screening method for cognitive impairment. Dementia and Geriatric Cognitive Disorders, 18, 172179.CrossRefGoogle ScholarPubMed