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CLOX: An Executive Clock Drawing Task: Journal of Neurology, Neurosurgery, and Psychiatry June 1998
CLOX: An Executive Clock Drawing Task: Journal of Neurology, Neurosurgery, and Psychiatry June 1998
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Age (y) 24.4 (4.3) 76.0 (11.6)* 75.8 (8.5)* 73.8 (9.2)* 76.5 (7.9)*
Education (y) 14.6 (1.2) 14.9 (2.2) 12.7 (2.8)* *** 13.4 (2.1)* *** 12.2 (3.1)* ***
EXIT25 4.2 (2.2) 8.8 (3.7)* 26.8 (7.5)* *** 31.1 (6.9)* *** 23.7 (6.3)***‡‡‡
MMSE 29.3 (0.9) 29.1 (1.3) 16.4 (6.9)* *** 12.0 (6.7)* *** 19.7 (5.0)***‡‡‡
CLOX1 13.2 (1.6) 12.1 (2.6)* 4.6 (4.5)* *** 2.1 (3.3)* *** 6.5 (4.4)***‡‡‡
CLOX2 14.2 (1.2) 14.2 (1.0) 8.3 (5.3)* *** 3.4 (3.9)* *** 12.0 (2.4)***‡‡‡
AD=Alzheimer’s disease.
*P<0.05 v young adults.
***P<0.001 v well elderly cases.
‡‡‡P<0.001 v patients with AD with MMSE constructional impairment.
failures rather than ECF related failures, (2) ropsychological testing, and functional status
bedside mental status examinations are either evaluation. Clinical data were confirmed by
indirectly sensitive to ECF failures or ignore family members or other available caregivers.
them altogether, and (3) the possible qualita- All pertinent laboratory results and neuroimag-
tive diVerences in CDT failures arising from ing studies were reviewed. The patients with
true constructional as opposed to ECF related Alzheimer’s disease were further divided into
pathology are not routinely assessed.20 Al- those with (n=19) and those without (n=26)
though several authors have commented on the gross constructional impairment on the mini
sensitivity of CDTs to “abstract” thinking or mental state examination (MMSE). Table 1
“complex behaviour”, there have been no compares these groups on selected clinical
eVorts to grade the CDT as an executive task, variables.
nor to divorce the executive control of clock
drawing from drawing itself. We expect that a INSTRUMENTS
significant proportion of the variance in CDT Subjects were interviewed by trained physi-
failures is in fact the product of executive dys- cians using the CLOX, EXIT25, and MMSE.
control. In this paper, we describe a clock The CLOX was scored blind to the other
drawing task which has been designed specifi- instruments. Each instrument is briefly de-
cally to discriminate executive and non- scribed below.
executive elements.
The executive clock drawing task (CLOX)
Methods The CLOX has been divided into two parts to
SUBJECTS help discriminate the executive control of clock
The CLOX instrument was first piloted in a drawing from clock drawing itself. The patient
sample of 62 young adult undergraduates is first instructed to draw a clock on the back of
(mean age 24.4 (SD 4.3) years) attending the the CLOX form (see fig 3). He or she is
University of Texas at San Antonio. This refer- instructed only to “Draw me a clock that says
ence group was compared with 90 elderly sub- 1:45. Set the hands and numbers on the face so
jects, selected from two clinical settings. Forty that a child could read them.” The instructions
five were recruited from the independent living can be repeated until they are clearly under-
apartments of a large retirement community. stood, but once the subject begins to draw no
All were free of depression and self reported further assistance is allowed. The subject’s per-
impairment in activities of daily living. The formance is rated according to the CLOX
mean geriatric depression scale (GDS short directions, and scored as “CLOX1”.
form)21 score was 1.2 (SD 1.5). Scores >07/25 CLOX1 reflects performance in a novel and
are considered “depressed”. The mean inde- ambiguous situation. The patient is presented
pendent activities of daily living score for this only with a blank surface and no further
group was 13.7 (SD 0.77). We further required guidance regarding the task. He or she is
that these cases scored no less than 1.0 SD responsible for choosing the clock’s overall form
below the mean for 25 year old subjects on both (a digital or analog face, alarm clock, wrist
the verbal and performance subscales of the watch, or wall clock, etc), its size, position on
Weschler adult intelligence scale. This helps to the paper, elements (hands, numbers, date
assure us that the elderly control group is free indicators), the forms of these elements (hands
of incipient dementias. Less than 25% of inde- as arrows, relative lengths, roman v arabic
pendent living septuagenarians at this retire- numerals, etc). Furthermore, the patient must
ment community can pass this stringent crite- also initiate and persist in clock drawing
rion. Informed consent was obtained before through a sequence of constructional actions
the evaluation of both control groups. (usually drawing the outer circle, followed by
The remaining 45 elderly subjects were out- placing the numbers if any, followed by setting
patients diagnosed with probable Alzheimer’s the time). Finally, he or she must monitor
disease using National Institute of progress as the task unfolds, both anticipating
Neurological Communicative Disorders and (placing the 12, 6, 3, and 9 first) and/ or
Stroke (NINCDS) criteria.22 All had correcting errors as they occur.
undergone comprehensive geriatric assess- It is just as important to note what a patient
ments, including examination by a geropsy- does not do during a clock drawing task. Our
chiatrist. Each received a history, physical CLOX form and its verbal instructions have
examination, mental state examination, neu- been designed to distract the subject with
590 Royall, Cordes, Polk
Figure 3
CLOX: an executive clock drawing task 593
because the combination of EXIT25 and well elderly subjects and patients with Alzheim-
MMSE scores, which takes much longer er’s disease. Significant fractions of both
(25–30 minutes) to administer, gave a less sat- groups presented below the fifth percentile for
isfactory performance (Wilkes’ lambda =0.73; young adult controls on one or more CLOX
F(2,34)=6.4; p<0.005; 75.7% correctly identi- subscales (n =37 (82%) of Alzheimer’s disease
fied). cases; n =7 (16%) of controls). The pattern of
these deficits in Alzheimer’s disease suggests a
INTERPRETING CLOX SCORES generalised dementing illness. Twenty
CLOX scores were tightly distributed in young seven(60%) patients with Alzheimer’s disease
adult subjects (CLOX1 =13.2 (1.6); CLOX2 failed both CLOX subscales. By contrast, no
=14.2 (1.2) (table 1)). Thus, a CLOX1 score controls presented below this threshold on
of 10/15, or a CLOX2 score of 12/15, both subtests.
represents the fifth percentile (2 SD below the The cognitive impairments we found in well
mean) for the young adult reference group (fig elderly subjects suggest relatively isolated ECF
2). Cases presenting in box A of fig 2 have impairment. Six (14%) elderly controls failed
scored above the fifth percentile for young only the CLOX1 subscale, 12 (27%) failed the
adult controls on both CLOX subscales. Cases EXIT25 at 10/50. By contrast, only one elderly
in box B are below the fifth percentile for their control (2.2%) failed the MMSE at 24/30. As
unprompted CLOX1 score, but not the copied Alzheimer’s disease aVects posterior cortical
condition (CLOX2). Those in box D would regions before invading the frontal cortex,35
have constructional>executive impairment. isolated ECF impairment is not likely to repre-
Cases in box C have significant impairment sent early Alzheimer’s disease. On the contrary,
relative to young adults on both CLOX many non-Alzheimer’s disease medical disor-
subscales. The regression line for the 45 ders, including subcortical stroke, depression,
patients with NINCDS probable Alzheimer’s polypharmacy, and hypothyroidism might be
disease enters this box from box A (fig 2). expected to aVect ECFmore than posterior
Cases presenting above this regression line cortical function.18 20 The CLOX may provide a
have more executive impairment than would be practical means to screen for these “reversible”
expected for an average Alzheimer’s disease dementias in community settings.
case at that CLOX2 score. Cases presenting However, independent of these diseases,
below this regression line would represent there are also reports of (1) isolated age associ-
greater constructional impairment than could ated decline in ECF testing,36 37 (2) dispropor-
be expected for patients with Alzheimer’s tionate frontal system atrophy on MRI,38 and
disease at similar CLOX1 scores. Figure 2 also (3) disproportionate frontal system hypome-
presents the CLOX scores for the 45 elderly tabolism by SPECT in healthy elderly controls
controls. It is immediately apparent that a sig- relative to young adults.39 These studies
nificant fraction of this group (n=6, 14%) is support the phenomenological overlap be-
presenting in box B (with relatively isolated tween well elderly subjects and those with iso-
executive impairment relative to both patients lated frontal system dementias.40 41 The CLOX
with Alzheimer’s disease and young adult con- may provide a means of detecting this condi-
trols. tion. In this study, only age, CLOX1, and
EXIT25 scores discriminated between our
Discussion young and elderly control groups.
In this study we have shown that a clock draw- The CLOX2 subtest, like traditional cogni-
ing task can be constructed that is both tive tests, implicitly targets posterior cortical
internally consistent and strongly associated deficits. Recent studies suggest that differences
with an executive test measure. We can confirm in right parietal metabolism discriminate
the impression of Huntzinger et al33 that clock Alzheimer’s disease subgroups with and with-
drawing would be useful to clinicians in busy out constructional impairment.32 42 43 CLOX2
outpatient practices. The CLOX is reliable, scores discriminate Alzheimer’s disease sub-
easy to administer, and well tolerated by elderly groups with and without gross constructional
patients. Because many elderly adults are impairment, even after adjusting for severity of
resistant or non-compliant with formal at- dementia, whereas the pattern of CLOX1/
tempts to document their cognitive perform- CLOX2 scores accurately classifies 91.9% of
ance, a clock drawing assessment could im- patients with Alzheimer’s disease on this basis.
prove testing compliance, especially in In this regard, our data are consistent with
outpatient, community, and residential settings those obtained by Sawada et al.44 They showed
where professional examiners are not available. qualitative diVerences among patients with
We found that CLOX1 and CLOX2 scores dementia for the pattern of SPECT perfusion
were strongly associated with both the EXIT25 deficits in the right parietal and frontal cortices.
and MMSE. These associations persisted after As we have noted, the patients with dementia
adjusting for age and education, although edu- diVered from elderly and young adult controls
cation’s range was limited by our sample in both indices. All patients with dementia
frame.34 Construct validity is suggested by the showed frontal cortical hypometabolism rela-
finding that the EXIT25 accounted for most of tive to controls, but subsets among them
the variance in CLOX1 scores, after adjusting diVered with in right parietal perfusion. The
for the MMSE, whereas the opposite was relation of the CLOX to cortical pathology/
found for CLOX2 scores. perfusion has yet to be determined.
Subject performance on CLOX subscales In summary, the CLOX is an internally con-
disclosed interesting information about both sistent measure that is easy to administer and
594 Royall, Cordes, Polk
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