Basics of Clock Face Drawing Test

1. CLOCK FACE DRAWING TEST:
METHODS & IMPLICATIONS
Dr.S.K. Kar
Associate Professor of Psychiatry
KGMU, Lucknow, U.P

2. Clock face drawing test: Overview
• Developed in early 1900s for evaluation of soldiers
with head injury (particularly to parietal and
occipital lobes)
• Injury to parieto-occipital area: Difficulty in
composing images (appropriate number of parts,
correct size & orientation):::: CONSTRUCTIONAL
APRAXIA
• Skills required to draw a CLOCK
• Ability to follow directions
• Language comprehension
• Visualize orientation of the object
• Execute normal movements (coordination)
• Conceptualization and planning
• Number sequencing
Mc Gee S (2018): Mental Status Examination: Evidence based physical diagnosis; 4th Edition

3. Neurobiological correlates of
clock face drawing test
Eknoyan D, Hurley RA, Taber KH. The clock drawing task: common errors and functional
neuroanatomy. The Journal of neuropsychiatry and clinical neurosciences. 2012
Jul;24(3):260-5.

4. Clock Face Drawing Test in Dementia
Dementia Sensitivity Specificity
Abnormal clock drawing
test
36-75 72-98
MMSE score ≤23 53-100 71-99
Mc Gee S (2018): Mental Status Examination: Evidence based physical diagnosis; 4th Edition
CFDT is a non-verbal test of cognition

5. Various scoring systems are used for CFDT.

6. Sunderland T, Hill JL, Mellow AM, Lawlor BA, Gundersheimer J,
Newhouse PA, et al. Clock drawing in Alzheimer's disease: a novel
measure of dementia severity. J Am Geriatr Soc 1989;37:725-9.

7. Watson YI, Arfken CL, Birge SJ. Clock completion: an objective
screening test for dementia. J Am Geriatr Soc 1993;41:1235-40

8. Other methods
• Alzheimer's Disease (AD) Cooperative Study
scoring system:
• The AD Cooperative Study scoring system uses a 5-point
scale, with higher numbers indicating better
performance.
• Scoring: One point each is assigned for drawing an
approximately circular face, symmetry of number
placement, correctness of numbers, presence of two
hands, and hands showing correct length or time
• Wolf-Klein method:
• In the Wolf-Klein method, subjects are merely asked to
“draw a clock” on a preprinted circle.
• Scoring: Their scoring system has 10 anchor points
which pertain only to the spacing of the numbers; time
setting is not assessed.
• Sample anchor points include: 10“normal”; 7 “very
inappropriate spacing;” 4 “counter-clockwise rotation;”
and 1 “irrelevant figures”
• Shulman method:
• One of the oldest scoring systems used was by Shulman
et al.
• They developed a 5-point scale of hierarchical errors
with the higher score for a failed attempt to draw a
clock.
• In a subsequent study, this scale was reversed and the
maximum points given to a perfect clock
• Many other methods (Manos and Wu system;
Mendez system; Rouleau system; Pfizer Inc., and
Eisai Inc. System; Tuokko system etc)

9. Implications
 Fronto-temporo-parietal functioning
 Indicator of constructional apraxia
 Early screening for cognitive impairment
(Dementia)
 Useful in dementias like : AD, VD, FTD
 Also useful in DELIRIUM, FOCAL CEREBRAL
LESIONS, HUNTINGTON’S DISEASE,
HEMINEGLECT, MULTIPLE SCLEROSIS,
SCHIZOPHRENIA
Poor performance may be
seen with: Old age,
Depression, Low
education, HypertensionAdvantage:
• Simple & Quick
• Little need of resources
• Can be administered to hearing impaired
• Easy to document graphically
• Easy to remember
Palsetia D, Rao GP, Tiwari SC, Lodha P, De Sousa A. The Clock Drawing Test versus
Mini-mental Status Examination as a Screening Tool for Dementia: A Clinical
Comparison. Indian J Psychol Med. 2018;40(1):1–10.