BRAIN AND COGNITION 18, 70-87 (1992)

Quantitative and Qualitative Analyses of Clock Drawings

in Alzheimer’s and Huntington’s Disease

ISABELLE ROULEAU

Department of Psychiatry, University of California, San Diego

DAVID P. SALMON

Department of Neurosciences, University of California, San Diego

AND

NELSON BUTTERS, COLLEEN KENNEDY, AND KATHERYN MCGUIRE

Department of Psychiatry, University of California, San Diego, and Psychology Service,

Department of Veterans Affairs Medical Center, San Diego

Although visuoconstructive impairment has been reported in both Alzheimer’s

(DAT) and Huntington’s (HD) disease, there is little knowledge concerning how
this cognitive deficit differs quantitatively and qualitatively in these two progressive
dementias. To address this issue, the present study compared performances on
the Clock Drawing Test (CDT: command and copy) of 25 DAT patients, 25
equally demented HD patients, and 25 elderly normal controls (NC). In the
command condition, both patient groups were significantly impaired compared to
the NC group. Although there was no significant difference between DAT and
HD patients’ total quantitative scores, a qualitative error analysis revealed a
number of dissociations between the two patient groups. Graphic difficulties, very
common in HD patients, were virtually absent in DAT patients; in contrast,
conceptual errors were almost exclusively seen in DAT patients and were related
to the severity of their dementia. Perseveration and “stimulus-bound” responses
were also more frequent in DAT patients, and both groups made visuospatial
errors. In the copy condition, the DAT, but not the HD, patients evidenced a

This study was supported by funds from the Medical Research Service of the Department
of Veterans Affairs, by NIA Grants AG-05131 and AG-08204 to the University of California
at San Diego, and by FRSQ (Fonds de la recherche en Sante du Quebec) Postdoctoral
Fellowship to Dr. Rouleau. All correspondence and reprint requests should be addressed
to Dr. Nelson Butters, Psychology Service (116B), Dept. of Veterans Affairs Medical Center,
3350 La Jolla Village Drive, La Jolla, CA 92161.

70
0278-2626192 $3.00
Copyright 0 1992 by Academic Press, Inc.
All rights of reproduction in any form reserved.
 VISUOCONSTRUCTIVE IMPAIRMENT 71

marked improvement in performance. These results indicate that while both DAT
and HD patients have significant visuoconstructive difficulties even in the early
stages of their disorders, the specific cognitive processes underlying their quan-
titative impairments are quite different. It is possible that the DAT patients’
conceptual errors are yet another indicator of the deterioration of their semantic
knowledge. (2‘ 1992 Academic Preu. Inc

INTRODUCTION
Studies comparing the neuropsychological profiles of Alzheimer’s
(DAT) and Huntington’s disease (HD) patients have demonstrated that
various forms of dementia may differ in terms of the quantitative and
qualitative features of their language, attention, and memory impairments
(for review, see Butters, Salmon, & Heindel, 1990b). Alzheimer’s pa-
tients, even in the early stages of their disorder, make frequent seman-
tically based naming errors and are more impaired on category than on
letter fluency tasks (Bayles & Tomoeda, 1983; Butters, Granholm,
Salmon, Grant, & Wolfe, 1987; Hodges, Salmon & Butters, 1991; Huff,
Corkin & Growdon, 1986). This pattern of deficits has been viewed as
an indicator of a deterioration in the structure of these patients’ semantic
knowledge (Chertkow & Bub, 1990; Martin, 1987; Martin & Fedio, 1983).
In contrast, patients with HD make relatively few naming errors, most
of which represent perceptual (rather than semantic) confusions, and are
equally impaired on both category and letter fluency tasks (Butters,
Salmon, Heindel, & Granholm, 1988b; Hodges et al., 1991). This profile
of impairments has been interpreted as representing HD patients’ defi-
ciencies in initiating retrieval strategies and in processing visuoperceptual
materials (Butters et al., 1990b; Hodges et al., 1991). Studies that have
compared DAT and HD patients’ attentional abilities have noted greater
deficits in HD than in DAT patients (Brandt, Folstein, & Folstein, 1988;
Folstein, Brandt, & Folstein, 1990; Starkstein et al., 1988; Troster, Jacobs,
Butters, Cullum, & Salmon, 1989).
Differences between DAT and HD patients are apparent on both ex-
plicit and implicit memory tasks. Patients with DAT seem unable to store
new information (Moss & Albert, 1988), evidence rapid rates of forgetting
(Butters et al., 1988a; Hart, Kwentus, Taylor, & Harkins, 1987; Moss,
Albert, Butters, & Payne, 1986; Welsh, Butters, Hughes, Mohs, & Hey-
man, 1991), are very prone to intrusion errors (Butters et al., 1987; Jacobs,
Salmon, Troster, & Butters, 1990), and have severe retrograde amnesias
even in the early stages of the disease (Beatty, Salmon, Butters, Heindel,
& Granholm, 1988; Sagar, Cohen, Sullivan, Corkin & Growdon, 1988).
On implicit memory tasks DAT patients have been reported to be im-
paired on lexical, semantic, and perceptual priming tasks but to perform
normally in the acquisition of motor skills (for review, see Butters, Heindel
& Salmon, 1990a). On the other hand, HD patients’ explicit memory
72 ROULEAU ET AL.

deficits have been characterized by retrieval rather than storage problems

(Butters, Wolfe, Granholm, & Martone, 1986; Butters, Wolfe, Martone,
Granholm, & Cermak, 1985; Delis et al., 1991), relatively normal rates
of forgetting (Butters 1988a; Delis et al., 1991; Moss et al., 1986), and
only mildly elevated tendencies to make intrusion errors (Butters et al.,
1987; Delis et al., 1991; Jacobs et al., 1990). On tests of remote memory,
HD patients are less impaired than DAT patients (Beatty et al., 1988).
When administered tests of implicit memory HD patients demonstrate a
pattern of deficiencies contrary to that reported for DAT patients. That
is, HD patients are impaired in the acquisition of motor skills but evidence
normal performance on lexical, semantic, and perceptual priming tasks
(Butters, Heindel, & Salmon, 1990a; Heindel, Salmon, & Butters, 1990).
These striking differences in memory have been attributed to the dys-
function of the mesial and lateral temporal lobes and of the corticostriatal
structures associated with DAT and HD, respectively (Butters et al.,
1990a; Heindel, Salmon, Shultz, Walicke, & Butters, 1989).
Despite these consistent findings for memory, language, and attentional
deficits, there have been relatively few studies of DAT and HD patients’
visuoperceptual and constructional impairments. Deficits in visuopercep-
tual processes have been reported in both DAT (Brouwers, Cox, Martin,
Chase, & Fedio, 1984; Huff et al., 1986) and HD patients (Fedio, Cox,
Neophytides, Canal-Frederick, & Chase, 1979; Portegal, 1971), but it is
not clear whether the deficits involve the same underlying mechanisms
(Brown and Marsden, 1988). Similarly, visuoconstructive impairments also
have been noted in both HD (Brandt & Butters, 1986; Butters, Sax,
Montgomery, & Tarlow, 1978; Fedio et al., 1979) and DAT patients
(Ajuriaguerra, Muller & Tissot, 1960; Brantjes & Bouma, 1991; Brouwers
et al., 1984; Gainotti, Caltagirone, Masullo, & Miceli 1980; Henderson,
Mack, & Williams, 1989; Kirk & Kertez, 1991; Martin, Cox, Brouwers,
& Fedio, 1985; Sunderland et al., 1989) on various tasks (e.g., drawings
of geometric patterns, objects, clocks; Block Design and Object Assembly
subtests of the WAIS-R), but again there is little knowledge as to how
these patients’ deficits differ in quantitative and qualitative terms.
In order to provide some initial comparisons of DAT and HD patients’
constructional and visuoperceptual impairments, the present study focuses
upon their performances on clock drawing tasks. Since it is possible to
identify the graphic, conceptual, perceptual, and spatial deficiencies that
underlie failures on such drawings (Henderson et al., 1989; Kaplan &
Delis, in press; Sunderland et al., 1989; Wolf-Klein, Silverstone, Levy,
Brod, & Breuer, 1989), clock drawing tasks seem most suitable for as-
sessing quantitative and qualitative differences between these patient
groups. Several detailed descriptions of the clock drawings of DAT pa-
tients have already appeared, but none of these reports have attempted
to compare these constructional deficiencies with those of another pro-
 VISUOCONSTRUCTIVE IMPAIRMENT 73

TABLE 1
AGE, EDUCATION,AND DEMENTIA RATING SCALE SCORE(DRS) (MEAN -+ SD) for the
DAT, HD, AND NC SUBJECTS

DAT HD NC

Age 71.00 (6.70) 49.84 (12.78) 70.88 (6.65)

Education 14.20 (2.79) 13.74 (2.32) 13.68 (2.75)
DRS 114.68 (20.07) 110.08 (27.08) 138.96 (3.20)

gressive dementia (Henderson et al., 1989; Kirk & Kertez, 1991; Sun-
derland et al., 1989). More specifically, DAT and HD patients, as well
as age-matched intact control subjects, are asked to draw a clock to
command and to set the hands to a specified time. To compare drawing-
to-command with copying ability, the patients and control subjects are
also asked to copy the drawing of a clock with the hands already set to
a specified time. A modified version of Sunderland et al.3 (1989) scoring
criteria and error categories are used in the analyses of all drawings.
METHOD
Subjects
A total of 75 subjects participated in this study. They were equally divided into three
groups: 25 patients with DAT, 25 HD patients, and 25 elderly neurologically intact normal
control subjects. The DAT and HD patients were matched for overall level of dementia
with the Dementia Rating Scale (DRS) (Mattis, 1976). All subjects were participants in the
research activities of the Alzheimer’s Disease Research Center (ADRC) at the University
of California at San Diego. As part of this program, all patients received a yearly com-
prehensive neurological and neuropsychological assessment.
The diagnosis of probable DAT was made by two senior staff neurologists using the
criteria developed by the National Institute of Neurological and Communication Disorders
and Strokes (NINCDS) and the Alzheimer’s Disease and Related Disorders Association
(ADRDA) (McKhann et al., 1984). Laboratory tests (e.g., CT scan, urinalysis, SMA-12,
T4, folate levels) were performed to rule out various viral, metabolic, or traumatic causes
of dementia. To reduce the possibility of including multi-infarct dementias, patients with a
score of 5 or greater on the Hachinski ischemia scale (Hachinski et al., 1975) were excluded
from the DAT group.
The diagnosis of HD was made by a staff neurologist on the basis of positive family
history for the disease, the presence of involuntary choreiform movements and dementia.
The functional capacities were assessed with Shoulson and Fahn’s disability scale (1979).
Nine of the patients were judged to be at stage II, 12 at stage III, and 4 at stage IV. In
addition to being matched on the DRS, and DAT and HD patients were equated for years
of education.
The normal elderly control subjects (NC) were selected to match DAT patients for age
and for education. Any subject with a history of alcoholism, drug abuse, or serious neu-
rological or psychiatric condition was excluded from the study.
The demographic data for the three groups are shown in Table 1. A one-way analysis of
variance (ANOVA) of the mean age showed a highly significant group difference [F(2,
72) = 44.07, p < .OOl]; post hoc analysis revealed that HD patients were significantly
younger than both DAT patients [t(48) = 7.33, p < .OOl] and NC subjects [t(48) = 7.30,
74 ROULEAU ET AL.

p < .OOl]. There was no significant difference in age between DAT and NC subjects [t(48)
< 11. A one-way ANOVA showed no significant difference in the mean education levels
of the three groups [F(2, 70) < 11. There was no significant difference between DAT and
HD patients in the severity of dementia, as assessed by the DRS [t(47) < 11, and both
patient groups were significantly impaired compared to NC subjects (p < .OOl).

Material and Procedures

The Clock Drawing Test (CDT) adopted from the Boston Parietal Lobe Battery (Good-
glass & Kaplan, 1972) was administered as part of the yearly comprehensive neuropsycho-
logical evaluation. The subjects were presented with an 8.5 x 11-in. blank sheet of paper
and a pencil, and the following instructions were given: “I would like you to draw a clock,
put in all the numbers, and set the hands for 10 after 11.” Following this drawing-to-
command condition, the patients were instructed to copy, as accurately as possible, a clock
from a model. The model which contained all the numbers on the clock, was 3 in. in
diameter and located on the upper part of an 8.5 x 11-in. sheet of paper. The hands on
the model were set for 10 after 11. The subject was instructed to copy the model on the
lower part of the same sheet of paper.
The resulting drawings were analyzed by three independent judges who were unaware of
the patients’ diagnostic group. Drawings under copy and command conditions were scored
separately in a different random order for each judge. Quantitative analyses using rating
scales were initially performed, followed by a qualitative error analysis.

Rating Scale
The clocks were first scored using Sunderland et al.‘s lo-point rating scale from worst
(score = 1) to best (score = 10) representation of a clock (Sunderland et al., 1989). However,
this scale proved difficult to apply according to the criteria provided since it assumes that
the representation of the hands is first and solely affected (score 6 to lo), and additional
errors in the representation of numbers and the clockface occur later (score 1 to 5). Con-
sequently, some drawings received very low scores on this scale because of minor errors in
the representation of numbers (added or missing numbers) even though the hands were
adequately set. To circumvent this scoring problem, the clocks were reevaluated with a new
lo-point scale (see Table 2) designed to independently assess the accuracy of the represen-
tation of the clockface (maximum, 2 points), the layout of numbers (maximum, 4 points),
and the position of the hands (maximum, 4 points).

Qualitative Error Analysis

In order to study the underlying mechanisms leading to deficits in clock drawing, a
qualitative error analysis was performed on the command and copy drawings. The following
dimensions were assessed:
1. Size of rhe clock. A clock was considered small if it measured less than 1.5 in. and
large if it measured more than 5 in.
2. Graphic difficulties. The lines were not precise, resulting either in distortions of the
clockface or in making the numbers difficult to read. The hands were not straight and
sometimes failed to connect in the middle. The overall performance appeared inaccurate
and clumsy. The graphic difficulties were rated according to their severity:
Mild: some distortions in tracing the clockface and/or the hands and/or the numbers
were present, but the overall performance remained adequate.
Moderate: distortions were evident, but the overall performance remained interpretable
(see Fig. la).
Severe: distortions were evident and precluded, in some cases, the unequivocal interpre-
tation of the overall performance (see Fig. lb).
 VISUOCONSTRUCTIVE IMPAIRMENT 75

TABLE 2
REVISED SCALE USED FOR SCORING THE CLOCK DRAWINGS

1. Integrity of the clockface (maximum: 2 points)

2: Present without gross distortion
1: Incomplete or some distortion
0: Absent or totally inappropriate
2. Presence and sequencing of the numbers (maximum: 4 points)
4: All present in the right order and at most minimal error in the spatial arrangement
3: All present but errors in spatial arrangement
2: Numbers missing or added but no gross distortions of the remaining numbers
Numbers placed in counterclockwise direction
Numbers all present but gross distortion in spatial layout (i.e., hemineglect, numbers
outside the clock)
1: Missing or added numbers and gross spatial distortions
0: Absence or poor representation of numbers
3. Presence and placement of the hands (maximum: 4 points)
4: Hands are in correct position and the size difference is respected.
3: Slight errors in the placement of the hands or no representation of size difference
between the hands.
2: Major errors in the placement of the hands
(significantly out of course including 10 to 11)
1: Only one hand or poor representation of two hands
0: No hands or perseveration on hands

3. Srimulus-bound response. The tendency of the drawing to be dominated or guided by

a single stimulus. Two types of such boundedness were apparent:
(A) The hands are set for 10 to 11 instead of 10 after 11. That is, the patient fails to
recode the “10” in “10 after 11” as a “2” in order to set the minute hand. He is thus
“attracted” to the strong stimulus source (i.e., “10”) rather than giving the appropriate
response that involves a more complex operation (i.e., setting the minute hand at “2”).
This type of error only occurs in the command condition since no recoding of the stimulus
is required in the copy condition (see Fig. lc).
(B) The time is written (in letters and/or numbers) besides the “11” or between “10 and
11” on the clock; hands are either absent (see Fig. 3a) or pointed toward “10” and/or “11”
(see Fig. lb). This second type of stimulus-bound response was also rated as a conceptual
error.
4. Conceptual deficit. In general, conceptual errors reflect a loss, or a deficit in accessing
knowledge of the attributes, features, and meaning of a clock. This category encompasses
a wide variety of errors:
(A) Misrepresentation of the clock itself (only a clockface without numbers or inappro-
priate use of numbers), suggesting the unavailability of a correct graphic representation of
a clock (see Figs. 2a-2c).
(B) Misrepresentation of the time on the clock: the hands are either absent or inadequately
represented (see Figs. 2c and 3e). The time is written on the clock (see Figs. 2b and 3a).
These errors suggest a deficit in the knowledge of the feature (the hands) that confer most
of the meaning of a clock, namely, communicating the time.
5. Spatial and/or planning deficit Deficit in the layout of numbers on the clock:
(A) Neglect of the left hemispace (see Fig. 3a).
(B) Deficit in planning, with gap before 12 or 3, 6, or 9 depending on the strategy used
in drawing (see Figs. 3b and 3~).
76 ROULEAU ET AL.

a) pt.2188: HD (command) b) pt 2038:HD (copy)

c) pt 2095: DAT (command) d) pt 2145: DAT (command)

FIG. 1. Samples of errors observed. Graphic difficulties: (a) moderate, (b) severe. Stim-
ulus-bound response: (c) associated with visuospatial deficit, (d) associated with a conceptual
deficit in representing the time on the clock.

(C) Deficit in spatial layout of numbers, without any specific pattern in spatial disorga-
nization (see Fig. 3d).
(D) Numbers written outside the clockface (see Figs. 3a and 3e).
(E) Numbers written counterclockwise (see Fig. 3f).
6. Perseverufion. In general, perseveration is defined as the continuation or the recurrence
of activity without an appropriate stimulus. In clock drawing, different types of perseverative
responses could be observed:
(A) Perseveration of hands: presence of more than two hands reflecting a failure to
terminate, when appropriate, the ongoing set of tracing the hands (see Figs. 4a and 4b).
(B) Perseveration of numbers: abnormal prolongation of numbers, such as writing beyond
“12” (See Fig. 4c) or inappropriate recurrence of the same numbers (see Fig. 4d).
The same three judges reviewed each clock independently, and an error was considered
present only if there was agreement between two of the judges.

RESULTS
The scores obtained for the clock drawings using both Sunderland et
al.% and the revised scale are presented in Table 3. The overall correlation
between the total scores (three judges) obtained with Sunderland et al.%
scale and with the revised scale was .89. The interrater reliability was
high in all conditions (i.e., all subjects pooled vs. separated by diagnostic
groups) varying from .86 to .97 with Sunderland et al.‘s scale and from
 VISUOCONSTRUCTIVE IMPAIRMENT 77

a) pt 2119: DAT (command) b) pt 2232: DAT (command)

c) pt 2179: DAT (command) d) pt 2179: DAT (copy)

FIG. 2. Samples of errors observed. (a-c) Conceptual deficit in the command condition;
(c,d) comparison of the command and copy conditions in the same patient.

.92 to .97 using the revised scale. The scores obtained with the revised
scale were retained for further analysis.
A two-way ANOVA (Group [DAT, HD, NC] x Condition [Command,
Copy]) with repeated measures across conditions yielded significant main
effects of Group [F(2, 69) = 9.52, p < .OOl] and Condition [F(l, 69) =
10.44, p < .005] and a significant Group x Condition interaction [F(2,
69) = 5.85, p < .005]. The results are presented in Fig. 5.
Post hoc comparisons revealed a significant difference between NC
subjects and DAT patients for both command [t(48) = 4.54, p < .OOl]
and copy [t(46) = 2.43, p < .05] conditions. The difference between NC
and HD subjects was also significant in both conditions [command: t(48) =
4.54, p < .OOl; copy : t(46) = 4.37, p < .OOl]. Although there was no
significant difference between DAT and HD patients in the command
[t(48) = < l] and in the copy conditions [t(46) < 11, further comparisons
(paired sample t test) between command and copy performances revealed
a significant effect for DAT patients [t(23) = 3.27, p < .005] but not for
78 ROULEAU ET AL.

B
0
doq&
a) pt 2176: DAT (command) b) pt 2075 HD (command) c)pt 612: HD (command)

d)pt 2216: DAT (command) e) pt 2151: DAT (command) f) pt 612: HD (command)

FIG. 3. Samples of various visuospatial errors observed. (a) Neglect of the left hemispace;
(b.c) planning deficit; (d) deficit in the spatial layout of numbers; (e) numbers written
outside the clockface; (f) numbers written in counterclockwise direction.

HD patients [t(23) < l] or for NC subjects [t(23) < 11. That is, the DAT
patients performed significantly better under copy conditions than under
command conditions, whereas the NC and HD subjects showed no dif-
ferences between these drawing conditions.

Qualitative Error Analysis

1. Size of the clock. A total of 11 subjects drew on command a clock
that was relatively small (< 1.5 in.) compared to what is usually observed
in normal subjects (2.5 to 4 in.): 7 patients with HD, 3 with DAT, and
1 NC. A relatively large clock (> 5 in.) was produced by a total of 9
subjects: 2 patients with HD, 7 with DAT, and no NC subjects (see Fig.
6). A x2 test of independence between Group (HD-DAT) x Size (small-
large) was significant [x*(l) = 4.33, p < .05], suggesting an opposite
tendency of DAT and HD patients to produce large (DAT) and small
(HD) clocks on command, respectively. In the copy condition, no subject
drew either a relatively small or large clock.
2. Graphic difJiculties. Although mild graphic difficulties were observed
in all subjects groups in both command and copy conditions, HD patients
 VISUOCONSTRUCTIVE IMPAIRMENT 79

a) pt 2222: DAT (copy) b) pt 2232: DAT (COPY)

C) pt 92: DAT (command) d) pt 2018: HD (command)

FIG. 4. Samples of perseverative errors observed. (a.b) Perseveration on hands; (c,d)
perseveration on numbers.

were more likely than DAT and NC subjects to have moderate (see Fig.
la) and severe (see Fig. lb) graphic difficulties (see Table 4). A x2 test
of independence between Group (HD-DAT-NC) and Graphic difficulties
(present-absent) was highly significant for both command [x2(2 df> =
27.49, p < .OOl] and copy [x2(2 @) = 16.32, p < .OOl] conditions.
An attempt was made to determine whether the HD patients’ graphic
difficulties were related to their overall disability and motor dysfunction.
When HD patients with no or mild graphic difficulties were compared
with those patients who evidenced moderate or severe deficits, no sig-
nificant differences were noted on the Shoulson and Fahn (1979) disability

TABLE 3
SCORNS OBTAINED (MEAN -t SD) FOR THE DAT. HD, AND NC SUBJECTS FOR CLOCK
DRAWINGS USING SUNDERLAND ET AI..‘S AND REVISED SCALES

DAT HD NC

Sunderland et al.‘s scale

Command 6.07 (2.X’)) 6.83 (2.83) 8.96 (1.52)
Revised scale
Command 6.30 (2.74) 6.X8 (2.14) 8.94 (1.12)
COPY 7.88 (2.10) 7.11 (1.92) 0.01 (0.02)
80 ROULEAU ET AL.

‘0 r

u g- 0 0

‘5

i:: +

6 -

5
M
O-0
NC
DA1

0-O HO

Command COPY
Condition
FIG. 5. Scores obtained in the command and copy conditions as a function of diagnostic
groups (NC, DAT, and HD).

scale [t(23) = 1.65, n.s.] and on measures of chorea [t(9) < l] and motor
impairment [t(9) < l] derived from the Chorea and Motor Impairment
scale (Folstein, Jensen, Leigh, & Folstein, 1983).

FIG. 6. Distribution of error types in HD and DAT patient groups in the command
condition.
 VISUOCONSTRUCTIVE IMPAIRMENT 81

TABLE 4
NUMBER OF DAT, HD, AND NC SUBJECTS PRESENTING WITH GRAPHIC DIFFICULTIES IN THE
COMMAND AND COPY CONDITIONS

Command COPY
DAT HD NC DAT HD NC

Mild 6 8 3 6 5 7
Moderate 0 I 0 3 11 0
Severe 0 5 0 0 4 0

3. Stimulus-bound response. Among the 75 subjects tested, 8 set the

hands at 10 to 11 in the command condition. In our sample, this behavior
was more common in DAT patients (5 cases) than in HD patients (2
cases; see Fig. 6) and NC subjects (1 case, aware of his error). This type
of performance may reflect, besides a stimulus-bound response, a mis-
understanding of the time setting (grammatical error) or a transient lapse
in attention (with subsequent awareness of the error). Although this per-
formance could be seen in isolation, it was often associated with other
deficits (Figs. lc, Id, and 4~). This error was never observed in the copy
condition.
4. Conceptual deficit. If patients in whom graphic deficits were too severe
to assess this dimension are excluded (3 cases with HD), a conceptual
deficit (see Figs. 2a-2c) was suggested in 16 of 46 demented patients: 13
DAT and 3 HD patients [x2(1 df, = 8.31, p < .Ol]. The frequent oc-
currence of this deficit in DAT patients might explain why, unlike the
HD patients, their performance significantly improved in the copy con-
dition (see Figs. 2c and 2d). This, however, was not the case for 3 DAT
patients who exhibited, in both the command and the copy conditions,
severe misrepresentation of the clock.
A comparison of the DAT patients’ DRS scores according to the pres-
ence (N = 13) or absence (N = 12) of a conceptual deficit (see Table
5) revealed significant differences in the total score [t(23) = 2.95, p <
.Ol], and in the Initiation/Perseveration [t(23) = 2.55, p < .05] and
Conceptualization [t(23) = 3.16, p < .Ol] scores. Attention, Construction,
and Memory scores did not differ significantly between patients with and
without conceptual deficit.
5. Spatial/planning de&it. A total of 23 patients committed visuospatial
errors (DAT, 10; HD, 13) in the command condition. Some errors were
observed equally often in both patients groups: this was the case for neglect
of the left hemispace (HD = 1, DAT = 1; see Figs. 3a-3f), deficit in
the spatial layout of numbers, without specific pattern in spatial disor-
ganization (HD = 3, DAT = 4; see Figs. lc, Id, and 3d) and numbers
written in counterclockwise direction (HD = 1, DAT = 1; see Fig. 3f).
82 ROULEAU ET AL.

TABLE 5
DEMENTIA RATING SCALE SCORES (MEAN, SD) IN DAT PATIENTS AS A FUNCTION OF THE
PRESENCE OR ABSENCE OF CONCEPTUAL ERRORS

Presence of Absence of
conceptual errors conceptual errors
N = 13 N = 12

Total DRS score 104.77 (23.42) 125.42 (6.27)**

Attention 33.46 (4.01) 35.42 (1.31)
Initiation/Perseveration 23.46 (8.45) 30.17 (2.55)*
Construction 4.77 (1.30) 5.42 (0.79)
Conceptualization 29.38 (7.95) 36.83 (l.SS)**
Memory 13.69 (5.30) 17.58 (4.78)

Note. Significant statistical differences between groups (**p < .Ol, *p < .05).

By contrast, some deficits were more frequent in a specific patient group:

deficits in planning (HD = 8, DAT = 1; see Figs. 3b and 3c) were
observed almost exclusively in HD patients, whereas the tendency to write
numbers outside the clock (see Figs. 2b and 3e) was more frequent in
DAT patients (HD = 1, DAT = 4; see Fig. 6). In the copy condition,
visuospatial errors were also common in both patients groups. However,
contrary to what was observed in the command condition, planning deficits
occurred almost as often in DAT (6 cases) as in HD patients (8 cases).
Neglect of the left hemispace and numbers written outside the clock,
respectively, were observed only once, both in DAT patients. No patient
wrote the numbers in a counterclockwise direction in the copy condition.
6. Perseveration. If the cases in which only one number was repeated
are excluded, three patients exhibited number perseverations (2 DAT, 1
HD; see Figs. 4c and 4d) and one DAT patient drew an additional hand
in the command condition. In the copy condition, perseveration of hands
was observed in two DAT patients (see Figs. 4a and 4b), but no subjects
exhibited perseveration of numbers.

DISCUSSION
Although both DAT and HD patients are impaired in their drawings
of clocks, it is quite evident that the processes underlying their low quan-
titative scores are quite distinct. The DAT patients’ tendency to commit
conceptual errors contributed greatly to their especially poor performance
on the drawing-to-command condition. When they lacked a model to
guide their drawings, the DAT patients appeared unable to retrieve the
specific attributes that define a clock and consequently were very impaired
in their attempts to draw an accurate representation. Their marked im-
provement under the copy condition further emphasizes that their drawing
deficiencies are not due primarily to graphic, motor, or even visuoper-
 VISUOCONSTRUCTIVE IMPAIRMENT 83

ceptual difficulties; rather, their deficit is likely due to a loss of the semantic
associations usually evoked by the word “clock.” The finding of an as-
sociation between the production of conceptual errors and lower scores
on the Initiation/Perseveration and Conceptualization sections of the DRS
also suggests that semantic impairments play a major role in DAT patients’
poor clock drawings. Thus, DAT patients’ well-documented impairments
on language tasks involving confrontation naming and fluency (Bayles &
Tomoeda, 1983; Butters et al., 1987; Chertkow & Bub, 1990; Hodges et
al., 1991; Huff et al., 1986; Martin & Fedio, 1983), on memory tests
requiring semantic encoding (Corkin, 1982; Granholm & Butters, 1988;
Salmon, Shimamura, Butters & Smith, 1988), and on construction tasks
involving the graphic representation of common objects may all reflect a
deterioration of the hierarchical structure of these patients’ semantic
knowledge. At the very least, the significant tendency of DAT patients
to manifest conceptual errors on a drawing-to-command task suggests that
such semantic deficits are ubiquitous even in the early and middle stages
of this disorder and may be evident on many neuropsychological tests.
Unlike the DAT patients, HD patients’ performance was characterized
by the presence of moderate and severe graphic deficits, a tendency to
draw small clocks, and planning deficits in the spatial layout of numbers.
The graphic deficits and small drawings are consistent with their marked
difficulties on tests of motor functions such as the Motor Steadiness Test
(Josiassen, Curry, and Mancall, 1983) and their low scores on most of
the WAIS-R Performance scale subtests (Butters et al., 1978; Fedio et
al., 1979; Folstein et al., 1990; Josiassen, Curry, Roemer, Debease, &
Mancall, 1982). Their planning deficits may be related to the frontostriatal
dysfunction commonly associated with HD (Brandt & Butters, 1986) and
are apparent on tasks such as the Wisconsin Card Sorting Test (Josiassen
et al., 1983) and the Picture Arrangement subtest of the WAIS-R (Butters
et al., 1978). As suggested by Kaplan and Delis (in press) a planning
deficit may also result from an inability to execute simultaneously two
sequential tasks (i.e., producing and writing the numbers in the right
order and spacing them equally around the clock), and may explain why
the HD patients often self-corrected their production.
Although visuospatial errors were noted in both patient groups, the
type of error differed: DAT patients tended to draw very large clocks,
to write the numbers outside the outline of the clock, and to commit
errors in the spatial layout of the numbers, whereas HD patients drew
small clocks and made a variety of visuospatial errors that could be at-
tributed to their inability to sequence or plan their motor responses. Some
evidence of spatial neglect was noted, albeit infrequently, in both patient
groups. However, the tendency to write all the numbers on the right side
of the clock could be an indication of a planning deficit rather than a true
neglect of the left hemispace.
84 ROULEAU ET AL.

Perseveration of numbers or hands and stimulus-bound responses,

though not totally absent in HD, were more frequent in DAT. This finding
is consistent with the observation that even in the early stages of the
disease, DAT patients often manifest numerous perseverations and stim-
ulus-bound behaviors on their cognitive evaluations (Moss & Albert,
1988). Although perseverative tendencies are commonly associated with
a frontal dysfunction (Lhermitte, Derouesne, & Signoret, 1972; Luria,
1965; Stuss & Benson, 1986), a number of studies have shown that HD
patients make fewer perseverative errors than do DAT patients on various
tasks such as verbal fluency, tactile reversal learning, and other episodic
memory tasks (Butters et al., 1983, 1988b; Freedman & Oscar-Berman,
1987). Why a patient group with frontostriatal damage (HD) should gen-
erate fewer perseverations than a group with primarily temporal deteri-
oration (DAT in the early stages) has not yet been adequately explained.
Besides the obvious clinical implications of these results for the diagnosis
and understanding of DAT and HD, the present findings, like those from
studies of memory and language, demonstrate the heterogeneity of the
cognitive deficits associated with various forms of dementia. Since our
patient groups were matched for overall level of dementia, the noted
qualitative differences cannot be attributed to differences in severity of
cognitive loss. Rather, it appears that dementia involving primarily limbic-
cortical regions are characterized by a pattern of losses which is clearly
distinct from those associated with dementias due to basal ganglia and
corticostriatal dysfunction. While it has not been established whether the
differences noted in the present study would also be found on a close
scrutiny of other constructional tasks and whether different types of basal
ganglia dementias would perform similarly, the results of this investigation
suggest that such comparisons are likely to yield valuable clinical and
theoretical insights.

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