International Psychogeriatrics (2015), 27:10, 1649–1660 

C International Psychogeriatric Association 2015

doi:10.1017/S1041610215000939

REVIEW
Can clock drawing differentiate Alzheimer’s disease from other
dementias?
...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Lynnette Pei Lin Tan,1 Nathan Herrmann,2 Brian J. Mainland3 and Kenneth Shulman4
1
Department of Psychiatry, Sunnybrook Health Sciences Centre, Canada; Department of Psychological Medicine, Tan Tock Seng Hospital, Singapore
2
Division of Geriatric Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre, Canada; Department of Psychiatry, University of Toronto,
Canada
3
Department of Psychology, Ryerson University, Toronto, Canada
4
Sunnybrook Health Sciences Centre, Canada; Department of Psychiatry, University of Toronto, Canada

ABSTRACT

Background: Studies have shown the clock-drawing test (CDT) to be a useful screening test that differentiates
between normal, elderly populations, and those diagnosed with dementia. However, the results of studies
which have looked at the utility of the CDT to help differentiate Alzheimer’s disease (AD) from other
dementias have been conflicting. The purpose of this study was to explore the utility of the CDT in
discriminating between patients with AD and other types of dementia.
Methods: A review was conducted using MEDLINE, PsycINFO, and Embase. Search terms included clock
drawing or CLOX and dementia or Parkinson’s Disease or AD or dementia with Lewy bodies (DLB) or
vascular dementia (VaD).
Results: Twenty studies were included. In most of the studies, no significant differences were found in
quantitative CDT scores between AD and VaD, DLB, and Parkinson’s disease dementia (PDD) patients.
However, frontotemporal dementia (FTD) patients consistently scored higher on the CDT than AD patients.
Qualitative analyses of errors differentiated AD from other types of dementia.
Conclusions: Overall, the CDT score may be useful in distinguishing between AD and FTD patients, but
shows limited value in differentiating between AD and VaD, DLB, and PDD. Qualitative analysis of the type
of CDT errors may be a useful adjunct in the differential diagnosis of the types of dementias.

Key words: clock-drawing test, Alzheimer’s disease, vascular dementia, Parkinson’s dementia, dementia with Lewy bodies, frontotemporal
dementia

Introduction execution (praxis), and executive function (Royall

et al., 1998; Shulman, 2000). While the literature
The CDT is a simple and valid screening on the use of the CDT in screening for the
tool for dementia (Shulman, 2000; Pinto and syndrome of dementia is extensive (Sunderland
Peters, 2009), correlating highly with global et al., 1989; Wolf-Klein et al., 1989; Mendez
cognitive function (Wolf-Klein et al., 1989; et al., 1992; Rouleau et al., 1992; Shulman,
Brodaty and Moore, 1997). A wide range of 2000), it is not clear whether the CDT is
cognitive functions is assessed by the CDT, valid for discriminating between the subtypes of
including orientation, selective and sustained dementias.
attention, auditory comprehension, verbal working Due to the variety of skills required for successful
memory, numerical knowledge, visual memory and completion of the CDT, specific errors have been
reconstruction, visuospatial organization, motor linked to different types of dementias (Eknoyan
et al., 2012). Hence, it would be reasonable to
assume that scores and the pattern of errors on
Correspondence should be addressed to: Lynnette Pei Lin Tan, Psychological
the CDT would differ between different dementia
Medicine Department, Tan Tock Seng Hospital, Annex Building Level 3, 11 and hence the CDT may aid in the differential
Jalan Tan Tock Seng, Singapore 308433, Singapore. Phone: +65 63577841; diagnosis of dementia. The type of clock-drawing
Fax: +65 63573088. Email: lynnette_tan@ttsh.com.sg. Received 14 Feb 2015;
revision requested 8 Apr 2015; revised version received 12 May 2015; accepted
errors can contribute to the clinical evaluation of
22 May 2015. First published online 3 July 2015. patients with suspected neuropsychiatric disorders
1650 L. P. L. Tan et al.
and syndromes as these errors likely represent
different neuropsychological functions (Eknoyan
et al., 2012). There are two general scoring
approaches – qualitative (Rouleau et al., 1992;
Kozora and Cullum, 1994; Libon et al., 1996) and
quantitative (Sunderland et al., 1989; Mendez et al.,
1992; Shulman et al., 1993; Watson et al., 1993).
There have been at least 19 CDT scoring systems
described since its use in the 1960s (Mainland et al.,
2014). Rouleau et al. and Libon et al. were among
the first to devise qualitative scoring systems for the
CDT (Rouleau et al., 1992; Libon et al., 1996).
They found that patients with AD demonstrated
different qualitative errors compared to patients
with subcortical deficits, such as Huntington’s
disease and ischemic VaD. The types of qualitative
errors that can be found also depend on the
method used for clock drawing, e.g. whether or
not a pre-drawn circle is used (Rouleau et al.,
1992; Libon et al., 1996). In one of the most
commonly used systems of evaluating qualitative
clock-drawing errors (Rouleau et al., 1992), errors
include: (i) graphical difficulties, in which lines are
not precise resulting in distortions of the clock face
or numbers that are difficult to read; (ii) stimulus-
bound responses, where there is the tendency of
the drawing to be dominated or guided by a single
stimulus e.g. the hands are set at 10–11 instead of
10 after 11; (iii) conceptual deficits, comprised of
deficits in accessing the knowledge of the attributes,
features, and meaning of a clock, resulting in a
drawing that does not look like a clock or drawing
with hands that do not communicate a time; (iv)
spatial/planning deficits, which are errors in the
layout of the numbers of the clock; and finally (v)
perseveration errors, which are the continuation or
recurrence of activity without appropriate stimulus
(e.g. presence of more than two hands or writing
of numbers beyond 12 or inappropriate recurrence
of numbers). Rouleau et al. (1992) found that
patients with AD were more likely to draw larger
clocks than patients with Huntington’s disease,
which may be a result of poor visuospatial planning
due to impairment of executive and visuospatial
functioning. Another finding was that graphical
errors were more common in Huntington’s disease
patients than AD patients, probably as a result
of secondary disruption of frontostriatal circuits
essential for the functions of fine motor control and
planning (Rouleau et al., 1992).
Currently, the literature reveals conflicting data
regarding the ability of the CDT to distinguish
patients with various types of dementia. The present
qualitative review aims to determine the usefulness
of the CDT in differentiating AD from the other
subtypes of dementia, including VaD, DLB, PDD,
and FTD.
Method
Study design
A literature search of electronic databases, MED-
LINE, PSYCINFO, and EMBASE was conducted.
Searches included the following keywords – clock
drawing or CLOX and dementia or Parkinson’s
Disease or AD or DLB or VaD. The search was
carried out in November 2013 and no limitation
on publication date was used. Citations from the
reference lists of previously gathered articles were
also manually searched to ensure that significant
work would not be missed. To determine the
usefulness of the CDT in differentiating AD from
the other subtypes of dementia and since AD is
the most common form of dementia, studies which
specifically compared performance on the CDT
between patients with AD and other dementias
were selected. Studies were assessed for inclusion
based on the following criteria: (1) studies that
used the CDT, independent of the scoring system
applied; (2) studies that compared AD patients with
patients of other types of dementias; (3) diagnosis
of dementia in patients were made based on
clearly defined criteria and/or autopsy; (4) studies
published in English.
The combined searches yielded 866 potentially
relevant references. Where a title or an abstract
appeared to describe a study that included the
comparisons of cognitive testing in people with
AD and other types of dementias, the full article
was retrieved and examined for relevance. Fifty-
three articles were retrieved and reviewed for final
inclusion; 33 of these had to be excluded because
they did not fulfill the selection criteria. Twenty
publications met the inclusion criteria. Given
the small and heterogeneous studies identified, a
quantitative review was not performed.
Results
Papers were published between 1992 and 2013 and
were mostly conducted in the USA (Barr et al.,
1992; Libon et al., 1993; 1996; Rascovsky et al.,
2002; Cahn-Weiner et al., 2003; Hamilton et al.,
2008; O’Brien et al., 2009; Wiechmann et al., 2010)
(n = 8). Two studies were from Italy (Moretti
et al., 2002; Cagnin et al., 2013) and two studies
were from Korea (Lee et al., 2009; 2011). The
remainder came from Israel (Heinik et al., 2002),
Japan (Kitabayashi et al., 2001), UK (McGuinness
et al., 2010), Brazil (Matioli and Caramelli, 2010),
Saudi Arabia (Sallam and Amr, 2013), Turkey
(Saka and Elibol, 2009), Sweden (Palmqvist et al.,
2009), and Canada (Blair et al., 2006). Eleven
studies (Barr et al., 1992; Libon et al., 1993; 1996;

Kitabayashi et al., 2001; Heinik et al., 2002; Moretti
et al., 2002; Lee et al., 2009; Matioli and Caramelli,
2010; McGuinness et al., 2010; Wiechmann et al.,
2010; Lee et al., 2011; Sallam and Amr, 2013)
compared CDT scores between AD and VaD
patients (Table 1). Six studies (Cahn-Weiner et al.,
2003; Lee et al., 2009; O’Brien et al., 2009; Saka
and Elibol, 2009; Lee et al., 2011; Sallam and
Amr, 2013) were identified which compared CDT
scores between AD and PDD patients (Table 2).
Four studies (Cahn-Weiner et al., 2003; Hamilton
et al., 2008; Palmqvist et al., 2009; Cagnin et al.,
2013) compared CDT scores between AD and
DLB patients (Table 3); and three studies (Moretti
et al., 2002; Rascovsky et al., 2002; Blair et al., 2006)
compared CDT scores between AD and FTD
patients (Table 4). Five of the studies (Moretti
et al., 2002; Cahn-Weiner et al., 2003; Lee et al.,
2009; 2011; Sallam and Amr, 2013) compared
CDT scores between AD patients and more than
one type of dementia. Patients were recruited
from memory clinics, geriatric assessment clinics,
neurology clinics, and research centers.
Methodological characteristics of the studies
There are considerable methodological variations
in the studies included. For example, sample
characteristics differ widely across studies. The
sample sizes varied from 50 to 235 patients,
with samples consisting of patients with differing
severity of dementia. Diagnosis of AD was mostly
based on the NINCDS-ADRDA (McKhann et al.,
1984). DSM-IV (Diagnostic and statistical manual
of mental disorders (4th ed., text rev.), 2000) was
used in one study (Heinik et al., 2002) and
two studies (Rascovsky et al., 2002; Hamilton
et al., 2008) had autopsy-confirmed diagnoses.
The diagnosis of probable VaD was made using
the NINDS-AIREN (Roman et al., 1993) criteria
in most studies, except one (Barr et al., 1992)
that used the DSM-III-R (Diagnostic and statistical
manual of mental disorders (3rd ed., revised.), 1987)
criteria, two (Heinik et al., 2002; Matioli and
Caramelli, 2010) that used the DSM-IV(Diagnostic
and statistical manual of mental disorders (4th ed.,
text rev.), 2000) criteria and one study (Libon
et al., 1996) used the California Criteria of Chui
et al. (1992). The diagnosis of DLB was made
according to the consensus criteria recommended
by the Consortium of DLB (McKeith et al., 1996)
in all the studies except one study had autopsy-
confirmed diagnosis of DLB (Hamilton et al.,
2008). PDD was diagnosed when the Parkinson’s
disease patients met the DSM-IV (Diagnostic and
statistical manual of mental disorders (4th ed., text
rev.), 2000) criteria for dementia with the clinical
Clock-drawing test in AD and other dementias 1651
diagnosis of the movement disorder at least 1 year
prior to the onset of the dementia or using the
clinical diagnostic criteria for dementia associated
with Parkinson’s disease (Emre et al., 2007). FTD
was diagnosed using the Neary et al. (1998) and
McKhann et al. (1984) criteria in one study (Blair
et al., 2006), the Lund and Manchester (Clinical
and neuropathological criteria for frontotemporal
dementia. The Lund and Manchester Groups,
1994) guidelines in another study (Moretti et al.,
2002), and was autopsy confirmed in the third study
(Rascovsky et al., 2002).
The versions of CDT used in the studies also
differed in the methods of administration and
scoring. The studies included used either a blank
sheet of paper with instructions to draw a clock
face or a pre-drawn circle for the CDT. Most
patients were instructed to set the clock hands
at 10 past 11 (11:10), although other times such
as 2:45 and 1:45 were also used less frequently
in the studies that utilized the Sunderland et al.
(1989) CDT, and the CLOX (Royall et al., 1998)
methods. Some studies used a clock-copying task
such as simple instructions to copy a clock shown
or the CLOX (Royall et al., 1998) test. Scoring
systems varied from a simple three-point system
(Hamilton et al., 2008) to a 15-point scoring system
(Freedman, 1994; Royall et al., 1998). Qualitative
error analyses, when included, followed the Rouleau
et al. system (Rouleau et al., 1992).
Differentiating AD from VaD
In general, quantitative scores evaluating per-
formance on the CDT were not shown to be
useful in differentiating AD from VaD (Table 1).
The findings were inconsistent across studies and
although AD patients were found to perform better
than VaD patients in clock copying scores in three
studies (Libon et al., 1993; 1996; Matioli and
Caramelli, 2010), the majority (Barr et al., 1992;
Libon et al., 1993; 1996; Kitabayashi et al., 2001;
McGuinness et al., 2010; Wiechmann et al., 2010)
found no significant differences in clock drawing to
command scores between AD and VaD patients.
One study (Moretti et al., 2002) found that AD
patients scored lower than VaD patients and two
studies (Heinik et al., 2002; Sallam and Amr, 2013)
found that VaD patients scored lower than AD
patients in the CDT. However, for the four studies
(Libon et al., 1996; Kitabayashi et al., 2001; Lee
et al., 2009; 2011) that included qualitative error
analyses, significant differences could be identified
between AD and VaD patients. VaD patients
appeared to demonstrate more spatial/planning
deficits (Kitabayashi et al., 2001; Lee et al.,
2009), graphical difficulties (Libon et al., 1996;
Table 1. Comparison of clock-drawing test between Alzheimer’s dementia and patients with vascular dementia

1652
AUTHORS COUNTRY PATIENTS N SCORING METHOD CLOCK-DRAWING TEST S U M M A R Y O F FI N D I N G S
............................................................................................................................................................................................................................................................................................................................................................................................................................................................

L. P. L. Tan et al.
Barr et al. (1992) US AD 37 (Albert, 1980; Shulman To command, score on a No significant differences in
VaD 31 et al., 1993) 0–5 scale. (Albert, 1980) command/copy CDT scores between
To copy, score on a 0–5 VaD and AD
scale. (Albert, 1980)
Heinik et al. Israel AD 52 (Freedman, 1994) Score on a 0–15 scale Freedman’s (Freedman, 1994) scoring
(2002) VaD 36 (Freedman, 1994) method total and hands subscore
control 26 significantly more impaired in VaD than
AD
Kitabayashi et al. Japan AD 67 (Rouleau et al., 1992) Score on a 0–10 scale No differences found between very mild
(2001) VaD 44 (Rouleau et al., 1992), AD and VaD
controls 8 Qualitative error analysis In mild dementia, spatial/planning deficits
(Rouleau et al., 1992) are more frequent in VaD than AD
In moderate dementia, graphic difficulties
are more frequent in VaD than AD
Lee et al. (2009) Korea AD 71 (Wolf-Klein et al., 1989), Four scoring protocols AD made more conceptual deficit errors
VaD 39 (Shulman et al., 1993), (Wolf-Klein et al., 1989; than VaD
PDD 33 (Watson et al., 1993), Shulman et al., 1993; VaD had more type A stimulus bound
(Manos and Wu, 1994) Watson et al., 1993; response than AD (10–11 instead of 10
(Rouleau et al., 1992) Manos and Wu, 1994), after 11)
Qualitative error analysis VaD had more spatial/planning deficits and
(Rouleau et al., 1992) perseveration errors (perseveration of
numbers) than AD
Lee et al. (2011) Korea AD 94 (Manos and Wu, 1994) Score on a 0–10 scale No clear differences in longitudinal
VaD 22 (Rouleau et al., 1992) (Manos and Wu, 1994), changes on CDT scores amongst the
PDD 119 Qualitative error analysis three dementia subtypes
(Rouleau et al., 1992) AD had more conceptualization errors than
spatial/planning deficits errors after 18
months from baseline compared to VaD
Libon et al. US AD 34 Adapted from Sunderland Score on a 0–10 scale No differences in clock drawing to
(1993) VaD 30 et al. (1989) (Sunderland et al., 1989) command score between AD and VaD
controls 34 On clock copying score, AD performed
better than VaD
Libon et al. US AD 31 Adapted from Sunderland Score on a 0–10 scale No differences in clock drawing to
(1996) VaD 27 et al. (1989) (Sunderland et al., 1989) command score between AD and VaD
Adapted from (Rouleau Qualitative Scale-2 of 10 On clock copying score, AD performed
et al., 1992) and (Kozora clock-drawing error types better than VaD
and Cullum, 1994) (Rouleau et al., 1992; On clock drawing to command, VaD made
Kozora and Cullum, more graphomotor errors∗
1994) On clock copying, VaD made more
executive control errors∗∗
Table 1. Continued.
AUTHORS COUNTRY PATIENTS N SCORING METHOD CLOCK-DRAWING TEST S U M M A R Y O F FI N D I N G S
............................................................................................................................................................................................................................................................................................................................................................................................................................................................

Matioli et al. Brazil AD 15 (Royall et al., 1998) CLOX-1 and CLOX-2 VaD scored worse than AD in CLOX-2
2010 (Matioli VaD 15 (Royall et al., 1998) (copy clock).
and Caramelli, controls 30 No significant difference in CLOX-1
2010) between AD and VaD
ROC curve displayed low specificity
(60.0%) for differential diagnosis
between the VaD and AD.
McGuinness UK AD 76 (Royall et al., 1998) CLOX-1 and CLOX-2 No significant difference in CLOX-1 and
et al. (2010) VaD 46 (Royall et al., 1998), CLOX-2 between AD and VaD
control 28 Drawing and copying
task, 15 point scoring
scale
Moretti et al. Italy AD 30 (Manos and Wu, 1994) Score on a 0–10 scale AD scored worst in CDT compared to
(2002) VaD 30 (Manos and Wu, 1994) VaD and FTD
FTD 30
Sallam et al. 2013 Saudi AD 51 CERAD; (Morris et al., Score on a 0–4 scale AD had significantly higher scores than
(Sallam and Arabia VaD 31 1989) (Morris et al., 1989) VaD
Amr, 2013) PDD 23 No significant differences in CDT scores
Other 86 amongst other groups

Clock-drawing test in AD and other dementias

dementias 30
Control
Wiechmann US AD 125 (Sunderland et al., 1989) Score on a 0–4 scale Four-point CDT (Sunderland et al., 1989)
(Wiechmann VaD 75 has good sensitivity (100%) and
et al., 2010) controls 24 specificity (70%) to distinguish between
normal and dementia
However, mean CDT scores were not
significantly different between AD and
VaD
OVERALL Qualitative analyses could
demonstrate differences between AD
and VaD
Inconsistent findings in total scores
between AD and VaD
∗ Includes clock size and shape of clock errors.
∗∗ Includes turning of paper when writing numbers, numbers written in counterclockwise order regardless of deficits in spatial layout or location within the clock and number perseveration errors.

1653
 1654
Table 2. Comparison of clock-drawing test results between Alzheimer’s dementia and Parkinson’s disease dementia patients
AUTHORS COUNTRY PATIENTS N SCORING METHOD CLOCK-DRAWING TEST S U M M A R Y O F FI N D I N G S

L. P. L. Tan et al.
............................................................................................................................................................................................................................................................................................................................................................................................................................................................

Cahn-Weiner USA AD 22 (Rouleau et al., 1992) Score on a 0–10 scale No significant group differences in global
et al. (2003) PD 17 (Rouleau et al., 1992), quantitative measure
DLB 20 Qualitative error analysis PD had more planning errors than AD
(Rouleau et al., 1992) CDT confers limited discrimination between
DLB/AD/PD
Lee et al. (2009) Korea AD 71 (Wolf-Klein et al., 1989), Four scoring protocols No significant group differences in global
VaD 39 (Shulman et al., 1993), (Wolf-Klein et al., 1989; quantitative measure in all four scoring protocols
PDD 33 (Watson et al., 1993), Shulman et al., 1993; AD made more conceptual deficit errors than PDD
(Manos and Wu, 1994) Watson et al., 1993; PDD had more type A stimulus bound response
(Rouleau et al., 1992) Manos and Wu, 1994), than AD (i.e. hands are set for 10–11 instead of
Qualitative error analysis 10 after 11.)
(Rouleau et al., 1992) PDD had more spatial/planning deficits (layout of
clock) and perseveration errors (perseveration of
numbers) than AD
Lee et al. (2011) Korea AD 94 (Manos and Wu, 1994) Score on a 0–10 scale No clear differences in longitudinal changes on
VaD 22 (Rouleau et al., 1992) (Manos and Wu, 1994), CDT scores amongst the three dementia
PDD 119 Qualitative error analysis subtypes
(Rouleau et al., 1992) AD had more conceptualization errors than
spatial/planning deficits errors after 18 months
from baseline compared to PDD
O’Brien et al. US AD 25 (Royall et al., 1998) CLOX-1 (Royall et al., No significant differences between CLOX-1 in
(2009) PDD 25 1998), Drawing task, 15 PDD and AD although PDD scored lower than
point scoring scale AD
Saka et al. Turkey AD 32 (Rouleau et al., 1992) Score on a 0–10 scale PDD score lower than AD
2009(Saka and PDD 26 (Rouleau et al., 1992; CDT also helpful in differentiating aMCI and
Elibol, 2009) aMCI 34 Strauss, 2006) PDMCI
PDMCI 19
Sallam et al. 2013 Saudi AD 51 CERAD; (Morris et al., Score on a 0–4 scale PDD score lower than AD
(Sallam and Arabia VaD 31 1989) (Morris et al., 1989) No significant differences in CDT scores amongst
Amr, 2013) PDD 23 other groups
Other 86
dementias 30
Control
OVERALL Qualitative analyses could demonstrate
differences between AD and PDD
PDD score lower than AD in CDT in two of
the six studies

Notes: aMCI, amnestic mild cognitive impairment; PDMCI, mild cognitive impairment associated with Parkinson’s disease.
Table 3. Comparison of clock-drawing test results between Alzheimer’s dementia and patients with Lewy bodies dementia
AUTHORS COUNTRY PATIENTS N SCORING METHOD CLOCK-DRAWING TEST S U M M A R Y O F FI N D I N G S
............................................................................................................................................................................................................................................................................................................................................................................................................................................................

Cagnin et al. Italy AD 45 (Mondini, 2003) Score on a 0–10 scale No difference between AD and DLB total score
(2013) DLB 81 (Mondini, 2003) In DLB group, DLB with visual hallucinations
scored significantly lower in CDT than DLB
without visual hallucinations
Cahn-Weiner USA AD 22 (Rouleau et al., 1992) Score on a 0–10 scale No significant group differences in global
et al. (2003) PD 17 (Rouleau et al., 1992), quantitative measure
DLB 20 Qualitative error analysis DLB had more conceptual errors than AD
(Rouleau et al., 1992) DLB had more planning errors than AD
CDT confers limited discrimination between
DLB/AD/PD. (The overall classification
accuracy of the type of dementia was 69% in the
discriminant function analyses.)
Hamilton et al. US AD 44 Not specified Clock drawing test- copy, No differences in baseline CDT scores between
(2008) DLB 22 scored 0–3 points AD and DLB

Clock-drawing test in AD and other dementias

(autopsy DLB with impaired clock-copy scores (<3)
con- declined more rapidly than those with intact
firmed) scores over 1–2 yr period.
CDT predicts rate of subsequent global decline in
DLB but not AD
Palmqvist et al. Sweden AD 66 (Shulman, 2000) Score on a 0–5 scale DLB had lower scores than AD
(2009) DLB 33 (Shulman, 2000)
OVERALL Qualitative analyses could demonstrate
differences between AD and DLB
Three out of Four studies showed no
difference in CDT scores between DLB and
AD

1655
1656 L. P. L. Tan et al.

............................................................................................................................................................................................................................................................................................................................................................................................................................................................
Kitabayashi et al., 2001), and perseveration errors

AD scored worst in CDT compared to VaD and

(Lee et al., 2009) than AD patients. When evaluated

conceptual deficits and spatial/planning errors

over a period of 18 months, AD patients tend to

Qualitative analyses could demonstrate

FTD had fewer stimulus bound responses,

discriminate FTD from control and AD.

Both global and qualitative analysis helped
show more conceptual errors than VaD patients

FTD performed better than AD in CDT

differences between AD and FTD

FTD score higher than AD in CDT
compared to baseline (Lee et al., 2011).

FTD scored higher than AD

S U M M A R Y O F FI N D I N G S
Differentiating AD from PDD
Patients with PDD scored lower than AD patients
in three of the six studies which compared CDT in
PDD and AD patients (O’Brien et al., 2009; Saka
and Elibol, 2009; Sallam and Amr, 2013), although
in one study, this was not statistically significant

Table 4. Comparison of clock-drawing test results between Alzheimer’s dementia and frontotemporal dementia patients

than AD
(O’Brien et al., 2009) (Table 2). In the other

FTD
three studies, no significant differences were found
in CDT scores between PDD and AD patients
(Cahn-Weiner et al., 2003; Lee et al., 2009; 2011).
Qualitative analyses of the type of errors seem to

CLOCK-DRAWING TEST

(Manos and Wu, 1994)

suggest a difference between AD and PDD patients.

Qualitative error analysis

(Rouleau et al., 1992),

specified (Salmon and

(Rouleau et al., 1992)

Command, copy clock;

In PDD patients, more spatial/planning errors were

Score on a 0–10 scale

Score on a 0–10 scale

scoring system not

observed compared to AD patients (Cahn-Weiner

Butters, 1992)
et al., 2003; Lee et al., 2009). AD patients made
more conceptual deficit errors than PDD patients
(Lee et al., 2009; 2011).

Differentiating AD from DLB

SCORING METHOD

(Rouleau et al., 1992)

In patients with DLB, no significant differences

(Salmon and Butters,

were found between total CDT scores in three of the (Manos and Wu,
four studies included (Table 3) (Cahn-Weiner et al.,
2003; Hamilton et al., 2008; Cagnin et al., 2013).
The fourth study however, found that DLB patients
1994)

1992)
had lower scores than AD patients (Palmqvist et al.,
2009). In the only study examining qualitative
differences between these groups, DLB patients
were found to have more conceptual and planning
25
36
25

30
30
30
28
14

errors than AD patients (Cahn-Weiner et al., 2003).

N

Interestingly, it was also found that DLB patients

PATIENTS

with visual hallucinations scored lower than DB

firmed)
(autopsy

patients without visual hallucinations in one study

Control

con-

(Cagnin et al., 2013), and another study showed

FTD

FTD

FTD
VaD
AD

AD

AD

that the clock-drawing score predicted the rate of

subsequent global decline in DLB but not AD
patients (Hamilton et al., 2008).
LOCATION

Canada

Differentiating AD from FTD

Italy

US

In FTD patients, all three studies (Moretti et al.,

2002; Rascovsky et al., 2002; Blair et al., 2006)
Blair et al. (2006)

found that FTD patients scored higher than

Rascovsky et al.

AD patients (Table 4). In the only study that

Moretti et al.

OVERALL
AUTHORS

examined the clock-drawing errors qualitatively,

(2002)

(2002)

FTD patients had fewer stimulus-bound responses,

conceptual deficits, and spatial/planning errors than
AD patients (Blair et al., 2006).

Discussion
This review suggests that qualitative analyses of the
CDT may be helpful for the differential diagnosis of
AD from other dementias such as VaD, PDD, DLB,
and FTD. Furthermore, CDT scores may also help
differentiate AD from FTD. However, quantitative
scores in general, regardless of the scoring system
used, were not useful for differentiating AD from
VaD, PDD, and DLB. This is likely due to
the intrinsic nature of the CDT assessing several
cognitive skills at the same time for its completion.
Hence although a single overall score is able to
demonstrate the presence of cognitive impairment,
it is limited in delineating specific domains of
cognitive impairment. An examination of the type
of CDT errors may be more useful in localizing the
domain of cognitive dysfunction and assist in the
diagnosis of the type of dementia.
Royall et al. hypothesized that the clock drawing
to command (CLOX1) is more indicative of
executive impairment than clock copying (CLOX2)
(Royall et al., 1998), which focuses more on
visuoconstructional abilities. Whilst there are some
studies that support this theory with lower scores in
CLOX1 than CLOX2 in VaD patients (You et al.,
2011), there are also studies that conclude that
CLOX2 is a more sensitive measure of executive
deficits (Libon et al., 1993; Cosentino et al., 2004).
This may be explained by AD patients being more
impaired in semantic knowledge, resulting in poorer
CLOX1 scores than VaD patients. This would
account for our finding that the total score of the
CDT does not appear to be a sensitive measure
to differentiate between AD and VaD. However,
based on the four studies in this review that included
qualitative analysis of the CDT between AD and
VaD patients, there is a suggestion that the type
of CDT errors may help to distinguish between
the two. Most studies agree that frontal executive
dysfunction is most characteristic of VaD (Roh
and Lee, 2014), and subcortical VaD differentially
affects the frontosubcortical circuits that mediate
fine motor control and planning. The spatial and
planning deficits of the CDT seen more commonly
in patients with VaD than AD are likely to be due to
subcortical involvement in VaD (Looi and Sachdev,
1999).
Patients with PDD or DLB generally have greater
visuospatial, attention, and executive function
impairment than AD patients (Ferman et al.,
2006; Salmon and Bondi, 2009). In this review,
spatial/planning deficits on the CDT were more
common in PDD or DLB patients than AD patients
(Cahn-Weiner et al., 2003; Lee et al., 2009; 2011).
As is the case with VaD, this is likely to be due to
subcortical involvement present in PDD and DLB.
Clock-drawing test in AD and other dementias 1657
Planning errors on the CDT have been shown to be
more common in patients with greater subcortical
involvement (e.g. Huntington’s disease), than those
with predominantly cortical involvement (Rouleau
et al., 1992). Conceptual errors were found to
be more common in AD than PDD patients in
two of the four CDT studies with qualitative
analyses (Lee et al., 2009; 2011). This may be
explained by the earlier impairment of semantic
memory in AD patients (Salmon and Bondi, 2009)
compared to patients with PDD. In the only
study, that included a qualitative analysis of the
CDT comparing AD and DLB patients, conceptual
errors were unexpectedly found to be greater in
DLB patients than AD patients (Cahn-Weiner
et al., 2003). The authors explain that picture
comprehension is affected in DLB patients due
to a combination of semantic and visuoperceptual
impairments and other studies have also found that
DLB patients demonstrate similar semantic deficits
compared to AD patients (Calderon et al., 2001;
Lambon Ralph et al., 2001). Given the difficulty in
clinically differentiating PDD and DLB from AD,
patterns of deficits in the CDT may have some
clinical utility in distinguishing between AD and
PDD/DLB patients, although quantitative scores
per se are not likely to be useful.
All three studies that administered the CDT
to AD and FTD patients found that FTD
patients consistently scored higher than AD patients
(Moretti et al., 2002; Rascovsky et al., 2002;
Blair et al., 2006). This finding is supported by
several studies which suggest that the impairment
in FTD is largely restricted to executive function
rather than other cognitive functions (Forstl
et al., 1996; Rascovsky et al., 2002). Another
study has also found that FTD patients perform
better on tests of visuospatial abilities sensitive
to the dysfunction of medial temporal structures
compared to AD patients (Perri et al., 2005).
In the only study that included a qualitative
analysis of the CDT comparing FTD and AD
patients, FTD patients had fewer stimulus-bound
responses, conceptual deficits, and spatial/planning
errors than AD. This is also in keeping with
another study showing that behavioral variant
FTD patients often perform in the normal range
on traditional executive function tests measuring
working memory, planning, mental flexibility,
response inhibition, and concept formation, at
initial evaluation (Gregory and Hodges, 1996; Perri
et al., 2005).
The comparability of the studies reviewed is
limited due to the substantial methodological
heterogeneity including the selection of the sample,
the modality of CDT being administered, and the
scoring system utilized. Despite these differences,
1658 L. P. L. Tan et al.
it still appears that the CDT score itself confers
limited discrimination between AD and VaD,
PDD and DLB, and should not be used in
isolation. Quantitative scores however, do appear
to discriminate AD and FTD. Notably, the studies
that included a qualitative analysis of the CDT
found several significant differences between the
type of errors made by patients with AD compared
to patients with VaD, PDD, DLB, and FTD.
Future studies should continue to evaluate the
qualitative aspects rather than the quantitative
aspects of the CDT. Qualitative analysis of the
CDT may aid as an adjunct tool in the differential
diagnosis of dementia.
Funding
None.
Conflict of interest disclosure
None.
Description of authors’ roles
K. Shulman and L. Tan formulated the research
question. N. Herrmann and K. Shulman supervised
the data collection. L. Tan collected, analysed
the data and wrote the paper. N. Herrmann, B.
Mainland, and K. Shulman assisted with writing
the article.
Acknowledgments
The authors would like to acknowledge Mr Henry
Lam for assisting with the library resources at the
Sunnybrook Health Sciences Centre in obtaining
the list of articles for this review.
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