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Comparative Case Study-l

Administration of Clock Drawing Test (CDT)

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TABLE OF CONTENTS
ABSTRACT.........................................................................................................................3
CHAPTER#1

METHOD..............................................................................................................................4

Subjects................................................................................................................................3

Instruments...........................................................................................................................3

Material.................................................................................................................................4

Procedure..............................................................................................................................4

CHAPTER#2

ADMINISTRATION OF THE TEST......................................................................................5

Identifying Data.....................................................................................................................5

Case History.........................................................................................................................5

Behavioural Observation......................................................................................................7

Test taking behavior.............................................................................................................7

Interpretation........................................................................................................................7

Quantitative Interpretation....................................................................................................7

Qualitative Interpretation......................................................................................................8

Mini-Mental status Examination Test(MMSE..........................................................9

Clock Drawing Test (CDT).....................................................................................10

CHAPTER#3

DISCUSSION AND CONCLUSION..................................................................................11

CHAPTER#4

LIMITATIONS AND SUGGESTIONS..............................................................................12

CHAPTER#5

REHABILITATION PLAN................................................................................................13

REFERENCES.................................................................................................................14

ANNEXURES...................................................................................................................17
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ABSTRACT
The present comparative case study comprises the administration of mini mental status
examination (MMSE) and clock drawing test (CDT). This study was carried out with two
male subjects among then them one was the patient and other was healthy subject and both
were 45 years old. After rapport development MMSE and CDT were administered on both
the subjects.. The patient scored 19 on MMSE which is below the cut-off score of 23 and
indicates mild cognitive impairment he scored 01 on CDT which lies below the cut off score
5 and indicate that her visual motor reproduction is very low. The healthy subject had no
neurological problem and scored 30 on MMSE suggesting his intact memory and he scored
10 on CDT which indicate his adequate visual motor reproduction. Besides qualitative and
quantitative interpretation, behavioural observation and test taking attitude of both the
subjects were also
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Chapter#01

METHOD
Subjects

In the present comparative case study two 45 years old male were selected one was a
neurological patient suffering from obstructive stroke and the other one was a healthy person.
Both belonged to the middle class families.

Instrument

For the present comparative case study two instruments used were the Mini Multi
Status Examination (MMSE) and Clock Drawing Test (CDT).

Mini-Mental Status Examination (MMSE)

The mini-mental status examination is a brief 30 point questionnaire test introduce by

Folstein et al (1975) that is used to screen for cognitive impairment. It is used to estimate the
extent of cognitive impairment at a given point in time and to follow the course of cognitive
changes in an individual overtime, thus making it effective to document an individual’s
response to treatment. The cut off score of the test is 23. It takes10 minutes for its
completion.

Clock Drawing Test (CDT)

The Clock drawing test (CDT) developed by Freedman et al. (1994) is a brief cognitive task
that can be used by physicians who suspect neurological dysfunction based on history and
physical examination. It is relatively easy to administer and can be utilized as a precursory
measure to indicate the likelihood of further deficits. The purpose of the clock-drawing test is
to identify cognitive dysfunction, particularly constructional apraxia; an impairment in activity
such as building, assembling, and drawings caused by parietal lobe lesions and executive
function to describe a loosely defined collection of brain processes whose role is to guide
thought and behavior in accordance with internally generated goals or plans. The clock-
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drawing test has also been used as a screening test for dementia, as well as for detecting
cognitive dysfunction in other neurological disorders, and can detect cognitive dysfunction in
schizophrenia. However, the clock-drawing test may also reveal information about patients
other than just their constructional abilities. CDT Score of 10 suggests that cognitive
impairment (CI) is absent, score of eight or nine must be interpreted as mild impairement, less
than eight indicates moderate and less than five severe impairment. In medically stable patients,
scores remain stable from one day to the next

Material

The material used for the present case study was comprised of white blank sheet, pencile
and eraser.

Procedure

The present comparative case study comprises the administration of CDT and MMSE on two
45 years old males. Among them one was suffering from obstructive stroke and the other was
a healthy person. The test taking attitude and behaviour of both the subjects were also
observed. No comments or any kind of additional instructions, which could make them
hesitant, were given while the subject were completing the test While reassurance was
provided during the test to enhance their confidence and to establish rapport. After the
administration with both the subject, scoring.
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Chapter#02

ADMINISTRATION OF THE TEST

Identifying Data

Identifying data Neurological patient Healthy person

Name A.Q M.H
Age 45 years 45 years
Gender Male Male
Education Matriculation FA
Area or origin Islamabad Islamabad
Father alive/dead Dead Dead
Mother alive/dead Dead Alive
No. of siblings 04 06
Birth order 1st born Middle born
Gender of siblings 2 sisters & 2 brothers 2 brothers & 4 sisters
Dependent/independent Independent Independent
Monthly income RS.35,000/- RS.60,0000/-
Family system Nuclear Nuclear
Marital status Married Married
No of issue 06 03
Handedness Right handedness Right handedness
No. of sessions 01 01
Socioeconomic status Middle class Upper middle class
Neurological deficit Hemorrhage stroke Nil
Neurological test used CDT & MMSE CDT & MMSE
Date of assessment 11.03.2019 7.03.2019
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Case history

Neurological patient Healthy person

The patient was 45 years old male The person was 45 years old female
belonging to a middle class family.He had belonging to an upper middle class family.
04 siblings. He was the 1st born in his He had 06 siblings. He was middle born in
family. He completed all her developmental his family. He completed all her
milestone timely. He had very good developmental milestone timely. He had
relations with his parents and siblings. very good relationship with his parents and
The onset of the illness started when he was siblings. He Started her education at the age
diagnosed with chronic kidney disease after of 05 and studied till her FA.He had 02 sons
the diagnosis he started remaining worried and 1 daughter. He was leading a happy
about his health.He developed the marital life.He had no neurological illness.
complaints of headaches and one day he
became unconscious and his family took her
to the hospital. His family thought that it
happened due to his condition but when he
was admitted in hospital and complete
medical examination was carried out and on
the basis of his reports. He was diagnosis
with obstructive stroke and after the onset of
illness his left side become paralized.The
history of hypertension and diabetes was
present in her history.

Behavioural observation

Neurological patient Healthy person

The patient was normally dressed and seated The person was very active, friendly and
in a restless posture. He was unable to very motivated during the whole session
maintain her eye contact. During the whole and she maintained a good eye contact. Her
session her pitch of voice was very low and pitch of voice was normal.
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he seemed to be lethargic. He had insight of

her problem.

Test taking attitude

Neurological patient Healthy person

During the whole session, the patient was During the session, the patient was sitting
not active. He seemed to be lethargic. He comfortably. She answered all the questions
was not very interested to perform the test. efficiently.

Interpretation

Qualitative interpretation

The patient scored 19 on MMSE which was below the cut off score of 23 which
indicates the presence of moderate cognitive impairment in him while the healthy subject
scored 30 MMSE which is the maximum possible score on the test of the patient which indicate
absence of any neurological impairment.The patient scored 01 on CDT which is below the cut
off score of 08 which also indicate his poor Visio-spatial and Visio-constructive abilities and
cognitive impairment. The healthy subject scored 10 on CDT which indicates the absence of
any Visio-spatial & Visio-constructive problem.

Qualitative interpretation

Mini Mental Status Examination

Categories Neurological patient Healthy person


Orientation The patient scored 06 out 10
which indicated that his
orientation was mildly
disturbed.
Registration He scored 03 out 03 on this
category which revealed that
his registration was intact.
Attention and calculation The patient scored 02 out of
05 on this category which
indicate his poor attention
and calculation
Recall She scored 02 out of 03 on
this category which indicates He scored 03 on this
that her memory was mildly
impaired.
Language The patient scored 02 out 02
on this category which
indicate the absence of
impairment in language.
Repetition He scored 0 on repetition
revealing her poor
comprehension abilities.
Stage command The patient scored 02 on this problem in comprehension.
category which indicates
that he had some problem to
follow the command.
Reading The patient scored 1 on this
category which indicates
that she had no reading
problem.
Writing The patient scored 01 on this He scored 01 on the
category but tremors were
present which indicate that
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The patient scored 10 on this
category which indicates
that his intact orientation
towards time,place and
person.
He scored 3 out of 3 which
indicate that registration was
intact.
The person scored 05 out of
the 05 which indicates no
impairment in attention and
calculation.
category which indicate that
his short term memory was
good.
The person scored 02 on this
test which shows that his
language function was
intact.
He scored 01 on this
category revealing no
He scored 03 on this
category which indicate no
problem to follow the
command.
He scored 1 which indicates
that he had no
reading/language problem.
category of writing which
indicate that he had no
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she might have motor problem in motor

difficulty.
He scored 0 on this design
which indicate his poor
motor incoordination.
Copying
coordination.
He scored 01 on his category
which indicates that his
motor coordination was
intact.

Clock Drawing Test (CDT)

Neurological patient Healthy person

The patient scored 01 on CDT which is The healthy person scored 10 on CDT. He
below the cut-off score of 8. He had had drawn a close figure which indicate his
successfully closed the circle. He was unable intact motor coordination. He also placed all
to write the numbers on their accurate the numbers accurately on their position
position which indicated his poor Visio which indicates his intact executive
spatial functioning. He was unable to show functions. His overall performance on CDT
the correct time which indicated his poor indicates his intact visual memory and visual
executive functioning. His overall motor reproduction.
performance on CDT suggest visual motor
impairment and poor visual motor
reproduction

Chapter#03
DISCUSSION AND CONCLUSION

The present comparative case study comprises the administration of mini mental status
examination (MMSE) and clock drawing test (CDT). This study was carried out with two male
subjects among then them one was the patient and other was healthy subject and both were 45
years old. After rapport development MMSE and CDT were administered on both the subjects..
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The patient scored 19 on MMSE which is below the cut-off score of 23 and indicates mild
cognitive impairment he scored 01 on CDT which lies below the cut off score 5 and indicate
that her visual motor reproduction is very low. The healthy subject had no neurological problem
and scored 30 on MMSE suggesting his intact memory and he scored 10 on CDT which
indicate his adequate visual motor reproduction. Besides qualitative and quantitative
interpretation, behavioural observation and test taking attitude of both the subjects were also
observed.

In a National Health Insurance Programme database in Taiwan compared more than 80,000
dialysis patients with the general population controls;these investigator described a nearly
threefold increase risk of ischemic stroke and six fold increase risk of hemorrhage stroke as
compared with the general population.This proves true in case of the present patient as he had
complaints of chronic kidney disease (CKD) agent of stroke in the patient which made her left
side mildly paralyzed.

The research, from Harvard University suggested that stress could be the as important
risk factor as smoking or high blood pressure for developing stroke. This correlates with the
present case as patient was also worried about her health which made her vulnerable to
develop stroke.

The difference in the quantitative and qualitative performance of both the subjects
indicates that there is a marked difference in the cognitive functioning of the patient suffering
from a neurological disorder i.e. hemmorgic stroke and the individual without such
difficulty.
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Chapter#04

LIMITATION AND SUGGESTIONS

The limitations of the present comparative study are as follows:

1. Less time was spent with the subjects due to shortage of the time available.

2. The patient’s performance was affected by her lack of interest besides impairment in visual
perception and motor abilities.

Some suggestions to overcome these limitations of this study are:

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1. In order to analyse the cognitive impairment more accurately some other valid
neuropsychological tests should also be used.

2. Some other diagnostic tool could be applied to validate the diagnosis further.

3. More time should have been spent with the subjects for better understanding their
difficulties. If three or four are sessions held with the patient it might help to take the
detailed information.

4. In order to control the effects of any extraneous variable the test should be conducted in a
separate room.

Chapter#05

REHABILITATION PLAN

Medication or drug therapy is the common treatments for stroke the most popular classes of
drug used to prevent or treat stroke are thrombolytics, anti thrombolytics prevent the
formation of blood clot that become lodge in a cerebral artery and cause stroke. The drugs
prevent clotting by decreasing the activity of platelets blood cells that contribute the property
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of blood. These drugs reduce the risk of blood clot formation thus reducing the risk of
obstructive stroke/ischemic stroke.

For most stroke patients physical therapy is the corner of rehabilitation process a physical
therapist used training exercises and physical manipulation of the stroke patient’s body with
the intent of restoring movement body and coordination. The aim of PT is to have a stroke
patient relearn simple motor activities such as walking, sitting, standing, lying down and a
process of switching of one type of movement to another.

Occupational therapy involving relearning daily activities. The goal of OT is to help the patient
become in dependent or semi dependent.

Meditate and mindful prayer help the mind and body to relex and focus .Mindfulness can
help people see new perspectives,develop self-compassion and forgiveness. When practicing
a form of mindfulness, people can release emotions that may have been causing the body
physical stress.

REFERENCES

Duvivier E.H, Pollack C.V., (2009).Stroke. In: Marx, JA, ed. Rosen's Emergency
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Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby

Elsevier; 2009: chap 100.

French J.A, Pedley T.A, (2008). Clinical practice. Initial management of stroke. N

Engl J Med. 2008;359(2):166-76.