The clock drawing test as a screening tool in

mild cognitive impairment and very mild

dementia: a new brief method of scoring
and normative data in the elderly

Monica Ricci, Martina Pigliautile,

Valeria D’Ambrosio, Sara Ercolani,
Cinzia Bianchini, Carmelinda Ruggiero,
Nicola Vanacore, et al.
Neurological Sciences
Official Journal of the Italian
Neurological Society

ISSN 1590-1874
Volume 37
Number 6

Neurol Sci (2016) 37:867-873

DOI 10.1007/s10072-016-2480-6

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 Author's personal copy
Neurol Sci (2016) 37:867–873
DOI 10.1007/s10072-016-2480-6
ORIGINAL ARTICLE
The clock drawing test as a screening tool in mild cognitive
impairment and very mild dementia: a new brief method
of scoring and normative data in the elderly
Monica Ricci1 • Martina Pigliautile2 • Valeria D’Ambrosio2 • Sara Ercolani2 •
Cinzia Bianchini2 • Carmelinda Ruggiero2 • Nicola Vanacore3 • Patrizia Mecocci2
Received: 17 September 2015 / Accepted: 9 January 2016 / Published online: 10 February 2016
Ó Springer-Verlag Italia 2016
Abstract many studies sustained that the clock drawing
test (CDT) was not able to accurately detect people with
CDR = 0.5. Other researchers have promoted the use of
scoring approaches with multiple scales that rate quantitative
and qualitative features of the production. Nevertheless,
these scoring systems are complex and time-consuming. We
propose a new brief CDT’ scoring system in order to find a
good measure for mild cognitive decline which is at the same
time easy to administer. we enrolled 719 subjects: n. 181 with
mild Alzheimer’s disease (AD); n. 200 with amnesic mild
cognitive impairment (MCI) and n. 338 healthy elderly
subjects (C). our CDT-three-cluster scoring system demon-
strated a good sensitivity and an excellent specificity to
discriminate MCI subjects from normal elderly (76 and
84 %, respectively) and an excellent sensitivity and speci-
ficity to discriminate patients affected by mild Alzheimer
disease (CDR: 1) from normal elderly (91 and 90 %,
respectively). We found that CDT’ score = 1.30 discrimi-
nate people with MCI, whereas a score = 4.38 discriminate
AD patients. The three-cluster-scoring-system demonstrated
a good diagnostic accuracy, taking into account those error-
Electronic supplementary material The online version of this
article (doi:10.1007/s10072-016-2480-6) contains supplementary
material, which is available to authorized users.
& Monica Ricci
monica.ricci@students.mq.edu.au
1
ARC Centre of Excellence for Cognition and its Disorders,
Macquarie University, Sydney, Australia
2
Institute of Gerontology and Geriatrics, University of
Perugia, Perugia, Italy
3
National Centre of Epidemiology, National Institute of
Health, Rome, Italy
items more predictive of cognitive decline: omission of
numbers or hands, writing numbers or hands in a wrong
position and writing numbers or hands in a different code.
Our CDT’ scoring system is very short and easy method
which can be used also by non-specialist.
Keywords mild Alzheimer’s disease
mild cognitive
impairment
clock drawing test
scoring system
Introduction
The clock drawing test (CDT) is a widely used test for
screening cognitive impairment and dementia [1–3]. It is a
multidimensional tool able to evaluate visuo-constructive
and visuo-spatial skills, symbolic and conceptual repre-
sentation, hemiattention, semantic memory, executive
function including organization, planning, and parallel
processing [3–6].
Several methods have been proposed for CDT scoring
[5, 7–13], but some are too complex and time consuming
and other too simple to get enough sensitivity and speci-
ficity for a screening test, ranging between 77–94 % and
65–96 %, respectively [1, 8, 14–19]. Moreover, recent
studies, found that normal elderly subjects commit a high
number of errors [20–23], suggesting that CDT’s perfor-
mances might be influenced by confounding variables,
such as age and education. In particular, one study reported
that normal elderly have difficulties with the layout of the
clock figure and the placement of the hands [22]. Specifi-
cally, 50.8 % of observed subjects had difficulties to place
the numbers in cardinal positions and 33.1 % failed to
differentiate correctly the hands. Almost half of these
errors were made by those aging over 80 years and with the
lowest education level.
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868
While there is a general agreement in considering the
CDT a useful test to detect moderate and severe dementia
[24], its utility in distinguishing patients with mild cogni-
tive impairment or mild dementia is still debated [19, 20,
24, 25]. Recently, a modified version of the Rouleau’
scoring method has been proposed, in order to evaluate and
score other supplementary drawing inaccuracies for
detecting patients with MCI [26]. However this scoring
system is complex and highly time consuming.
A simple and sensitive test is largely needed as
screening tool in outpatient settings, but its scoring and
interpretation should be easy to be handled also by non-
specialists. The purpose of this study was to build a new
brief, quantitative scoring method of the CDT to identify
subjects with MCI and mild Alzheimer’s disease in an
elderly population.
Methods and subjects
The study was developed in different phases with the aim
to (1) define a new scoring method of the CDT; (2) define
the influence of gender, age and education and, accord-
ingly, a correction grid; (3) validate this scoring method in
another population.
Phase I. In the Memory Clinic of the Geriatric Depart-
ment, University of Perugia, we enrolled 264 consecutive
subjects older than 65 years with mild (CDR: 1) [27]
Alzheimer Disease (AD) (N.79) based on NINCDS-
ADRDA criteria [28], with Mild Cognitive Impairment
(MCI) (N. 96) [29] and 89 cognitively healthy elderly (C).
Participants were provided with a blank sheet of A4
paper. The instructions were as follows: ‘‘Please draw a
clock face, and place all the numbers on it. Now set the
hands at 10 past 11. One rater (MR) analyzed and listed the
type of errors made by each subject and then scored its
severity according to a 5-point Likert scale (from 0 for a
perfect performance to 5 for the worst performance). Errors
on CDT were categorized based on the layout of the circle
(C), of the numbers (N) and of the hands (H). The fol-
lowing parameters were considered and analyzed: circle
diameter (C-diameter), circle shape (C-distortion), lack of
numbers (N-omission), repeated numbers (N-persevera-
tion), reverting the order of numbers on the clock face (N-
reversal), modifying number positions (N-position), draw-
ing the number outside the circle (N-outside), or upside
down (N-upturned), or with different coding system such
as Roman or Arabic (N-code); position of short and long
hands (H-position), lack of one or both hands (H-omis-
sion), drawing of more than two hands (H-perseveration)
and writing the digital time (H-code). Principal component
analysis, with Varimax rotation and Kaiser normalization,
was performed. After this analysis, a three-cluster-scale
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was built (see results), based on the extracted factors. Since
the drawing of circle did not affect the results, we decided
to perform the study in the phase II population with a pre-
drawn clock with a contour of 11 cm in diameter and the
instructions have been modified (see supplementary
material).
Phase II. We enrolled 145 free-living, cognitively
healthy subjects to clarify the influence of age and level of
education on CDT and calculate the correction factors. All
the subjects had no history of psychiatric/neurological
disorders and they did not report memory complain.
Phase III. In order to evaluate the validity of the new
scoring method, in the Memory Clinic we then enrolled 310
consecutive subjects with mild AD (N. 102), with MCI
(N.104) and 104 cognitively normal elderly. All CDTs
achieved by the subjects were scored with the new scoring
system by two independent raters (MP, VDA). Differences
amongst groups, sensitivity and specificity of the scale and
inter-rater reliability were analyzed. A sheet paper with a
pre-drawn circle was presented with the following instruc-
tions ‘‘This is supposed to be a clock. Please put the numbers
on the clock. Thereafter please set the time at 10 past 11’’.
All 719 subjects of this study underwent the MMSE
[30], and corrected scores were used for the analyses.
Statistical analyses were carried out using SPSS program
(version 22.0). Comparisons amongst groups were per-
formed with ANOVA and Tukey’s post hoc analysis.
Multiple regression analysis was performed to evaluate the
influence of the demographic variables (age, gender and
education). The ROC (receive operated characteristics)
curves were used to detect the optimal cut-off scores to
discriminate the three clinical groups.
Results
In Table 1, demographic and clinical characteristics and
CDT’s errors type observed in the phase 1 study population
are reported. Post-hoc analyses showed that AD patients
obtained worse performances compared with the C group
in N- and H-omission, N- and H-perseveration; in writing
the numbers in a reverse order (N-reversal) and with a
different code (N-code); to place numbers and hands in
wrong positions (H- and H-position). The MCI group
achieved worse performances compared with the C group
in N-position and H-omission, whereas the AD group
obtained impaired scores compared with the MCI group,
also, in N-reversal. No significant differences were found
amongst the groups on distortion and size of the circle; on
upturned numbers or numbers posed outside the circle and
on hands or code perseveration.
Principal component analysis was performed to reduce
the variables, deleting redundant items (Table 2). Six
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Table 1 Demographic and

AD N. 79 MCI N. 96 C N. 89 * p \ 0.05
clinical characteristics of phase
** p \ 0.01
I population (n. 264)
*** p \ 0.001

Age 76.5 (5.5) 75.2 (5.8) 73.3 (6.9) AD vs C *

Education 5.2 (3.5) 7.4 (4.7) 7.2 (4.2) AD vs C **
AD vs MCI**
MMSE 22.2 (3.2) 26.6 (2.2) 28.4 (1.4) AD vs C**
AD vs MCI**
MCI vs C*
CDT errors
C-diameter 4.79 (2.13) 5.24 (2.94) 5.49 (2.50) n.s.
C-distortion 0.05 (0.36) 0 (0.0) 0.5 (0.43) n.s.
N-omission 1.27 (1.66) 0.53 (1.41) 0.24 (0.89) AD vs C***
N-perseveration 0.22 (0.77) 0.13 (0.58) 0.01 (0.11) AD vs C*
N-reversal 0.51 (1.49) 0.12 (0.74) 0.06 (0.54) AD vs C**
AD vs MCI*
N-position 2.42 (1.97) 1.13 (1.6) 0.53 (1.07) AD vs C***
AD vs MCI***
MCI vs C*
N-outside 0.08 (0.58) 0.25 (1.05) 0.18 (0.92) n.s.
N-upturned 0.17 (0.65) 0.13 (0.66) 0.07 (0.37) n.s.
N-code 0.90 (1.72) 0.54 (1.39) 0.11 (0.56) AD vs C***
H-position 0.87 (1.50) 0.47 (1.03) 0.38 (0.88) AD vs C*
H-omission 2.56 (2.4) 1.05 (1.90) 0.34 (1.20) AD vs C***
AD vs MCI***
MCI vs C*
H-perseveration 0.06 (0.57) 0.03 (0.23) 0.02 (0.21) n.s.
H-code 0.21 (0.97) 0.21 (0.95) 0.03 (0.24) n.s.
C circle, N numbers, H hands

factors (namely N-omission and H-omission; N-code;
H-code; H-position; N-reversal and N-position) globally
accounted for the 72.8 % of total variance.
Taking into consideration the extracted factors, we
defined a new brief scoring method of the CDT, with three
clusters of errors. The first cluster (named Omission) is
represented by the first extracted components (omission of
numbers and hands); the second cluster (named Code) is
represented by the second and third extracted components
(code of numbers and hands, respectively); the third cluster
(named Position) is represented by the fourth, fifth and
sixth extracted components (wrong position of the hands,
numbers placed in a reverse order and wrong position of
the numbers, respectively). In each cluster, the severity of
errors was scored by a 5-point-likert-scale (see supple-
mental material).

Table 2 Principal component analysis (rotation method: Varimax with Kaiser normalization)
1 2 3 4 5 6 Eigenvalues % of variance % of cumulative variance

N-omission 0.83 1.99 18.116 18.106

H-omission 0.77
N-code 0.84 1.53 13.955 32.061
H-code 0.80 1.19 10.831 42.893
H-position 0.87 1.18 10.730 53.622
N-reversal 0.94 1.08 9.840 63.462
N-position 0.83 1.02 9.302 72.765

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870 Neurol Sci (2016) 37:867–873

In order to clarify the influence of the age, level of Table 4 Demographic distribution of the normative study sample
education and gender on the CDT we enrolled 145-healthy- Education Age
subjects (descriptive data and demographic distribution of
our sample are summarized in the Table 3 and 4). 60-69 70-79 80-90 Total
Multiple regression analysis considering age, education 5 18 39 9 66
and gender as independent variables reveal a trend towards 8 12 29 6 47
significance of these variables on the CDT [F(3) = 2.50 13 8 10 3 21
p = 0.06; age: T = 1.70 p = 0.09; education: -1.90 17 2 8 1 11
p = 0.06; gender: T = 0.45 p = 0.31]. Even though we Total 40 86 19 145
observed just a slight tendency to the significance of age
and education, we performed the correction factors for
these variables (Table 5).
Table 5 Correction factors to the CDT raw scores
The demographic characteristics of the phase III popu-
lation are summarized in Table 6. As expected statistical Education Age
differences amongst groups were observed on the MMSE. 60 65 70 75 80 85 90
Significant differences were also observed on age (AD and
MCI groups being older than the C group) and on educa- 5 0.17 0.05 -0.07 -0.19 -0.31 -0.43 -0.55
tion level (AD being less educated than MCI and C). A 8 0.29 0.18 0.06 -0.06 -0.18 -0.30 -0.042
multivariate analysis, with age and education as covariates, 13 0.51 0.39 0.27 0.15 0.03 -0.09 -0.21
showed a significant interaction between groups and CDT 17 0.68 0.56 0.44 0.32 0.20 0.08 -0.04
measures [F(4,610) = 11,4; p \ 0.001]. Post-hoc analyses
revealed that AD patients achieved worse performances
compared with MCI and C groups (p’s \ 0.001), and the groups (Fig. 2a), a cut-off of 1.87 on the CDT corrected
MCI group obtained worse performances compared with total score had a sensitivity of 91 % and a specificity of
the C group (p \ 0.001). In order to break down the 90 %; while in distinguishing the MCI group from the C
interaction, we computed differences between CDT mea- group (Fig. 2b), the CDT’s total score best cut-off was 1.30
sures (i.e., position minus omission, position minus code, with a sensitivity of 76 % and specificity of 84 %. When
omission minus code). One-way ANOVA revealed group the CDT was used to discriminate between the AD group
differences for all the new computed measures [position- and the MCI group (Fig. 2c), the best cut-off was 4.38 with
minus-omission score, F(2,307) = 8.5 p \ 0.001; position- a sensitivity of 65 % and specificity of 72 %. The inter-
minus-code score, F(2,307) = 82.3 p \ 0.001; omission- rater reliability was excellent for all CDT’ scores: 0.98 for
minus-code score, F(2,307) = 11.5 p \ 0.001]. Post-hoc total score, 0.98 for code score, 0.94 for position score and
analyses showed that on position-minus-omission score the 0.97 for omission score.
MCI group achieved the larger difference compared with
the AD and C group (p \ 0.01 and p \ 0.001, respec-
tively), no other group differences were evident; on posi- Discussion
tion-minus-code score all groups differ significantly from
each other (p’s \ 0.001); on omission-minus-code score Accordingly with other studies [31, 32], our results showed
the AD group obtained a larger difference compared with that the omission of numbers or hands, the wrong position
both the MCI and C group (p’s \ 0.001) and no other of numbers or hands and writing numbers in a different
group differences were noted (see Fig. 1). code are more related to cognitive decline than other
In order to find a cut-off with the best sensitivity and mistakes. Taking into consideration the extracted factors,
specificity, ROC analyses were performed using the CDT we built a new brief scoring method of the CDT, involving
total score corrected for age and education accordingly three clusters of errors. The first cluster (named Omission)
with the data reported in Table 5. Between AD and C is represented by the first components extracted (i.e.,

Table 3 Descriptive data of

Lowest score Highest score Mean Standard deviation
145-healthy control subjects
(phase II population) Age 60 90 71.99 6.50
Education 1 18 7.92 4.25
MMSE 24.7 30 28.44 1.75
CDT 0 7 0.66 1.10

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Table 6 Demographic and

AD MCI C *p \ 0.05
clinical characteristics of phase
N. 104 N. 102 N. 104 ** p \ 0.01
III population (n. 310)
M (SD) M (SD) M (SD) *** p \ 0.001

AGE 77.1 (5.7) 75.3 (5.7) 71.9 (6.8) AD vs C***

MCI vs C***
EDUCATION 5.7 (4.0) 7.3 (4.7) 8.1 (4.4) AD vs C***
AD vs MCI***
MMSE 21.7 (3.6) 26.2 (2.9) 28.7 (1.6) AD vs C***
AD vs MCI*** MCI vs C***
CDT scores Omission 2.21 (1.76) 0.82 (1.46) 0.05 (0.40) AD vs C***
AD vs MCI*** MCI vs C***
Position 2.86 (1.22) 2.16 (1.20) 0.57 (0.86) AD vs C***
AD vs MCI***
MCI vs C***
Code 1.17 (1.94) 0.68 (1.58) 0.07 (0.42) AD vs C***
AD vs MCI***
MCI vs C***
Total 6.09 (3.31) 3.57 (2.94) 0.67 (1.06) AD vs C***
AD vs MCI***
MCI vs C**

Recently, an interesting study on the modified Rouleau’

Fig. 1 CDT sub-scores. Omission, Position and Code sub-scores
obtained by the groups. Bars represent the standard error
omissions of numbers and hands); the second cluster
(named Code) is represented by the second and third
components extracted (i.e., code of numbers and code of
hands, respectively); the third cluster (named Position) is
represented by the fourth, fifth and sixth component
extracted (i.e., wrong position of the hands, numbers posed
in a reverse order and wrong position of the numbers,
respectively). In each cluster, the errors’ severity was
scored based on a 5-point-likert-scale (see supplemental
material). All groups showed significant differences on the
CDT using our brief method of scoring but most impor-
tantly, using 1.30 as cut-off, this measure can well distin-
guish between MCI and C whereas a cut-off of 4.38
discriminate AD patients.
system showed an excellent specificity of that method in
discriminating C versus MCI and MCI versus AD (88 and
100 %, respectively) [26]. Nevertheless, we have few
concerns on these results. The first is the low sensitivity
values in discriminating the groups, being around 39 %
between C and MCI and 58 % between MCI and AD. The
second concern is about the severity of illness amongst AD
patients. In fact, around 30 % (10 on 33) of AD patients
scored 2 on the CDR, revealing moderate severity levels of
dementia. It is our opinion, that this heterogeneity in a
small sample could have exacerbated the specificity value
between MCI and AD. Lastly, that scoring system is
complex and highly time consuming and we are in accord
with other authors in emphasizing the need for brief,
quantitative scoring approaches that clinicians can easily
use and interpret [3, 33–35].
There is a common consensus that age and level of
education have an impact on the CDT [e.g., 10, 15, 36],
however, our findings revealed that age and education had
just a slight influence on the CDT’s performance. In the
normative phase, our sample was not evenly distributed
across all the cells of demographic characteristics (as
showed in Table 4), with fewer subjects enrolled in the age
range 80–90 or in cells with higher education (i.e.,
17 years). It is our opinion that it might have obscured age
and education effects on CDT in our sample.
In spite of other studies that considered the integrity of
the clock face in the scoring system [23, 37], we suggested
a pre-drawn circle version, because no significant

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872
Fig. 2 ROC curve analysis between AD and C (a); MCI and C (b); AD and MCI (c), using CDT corrected total scores
differences were found amongst our groups on the diameter
and distortion of the circle. To sum up, it is our opinion that
our CDT’ scoring method could be easily used also by non-
specialists in detecting those patients at risk of dementia.
Future research
The proposed CDT scoring method demonstrated to be a
reliable tool for revealing initial cognitive decline. The
Italian normative data are also available for the Freedman
version of the CDT [38]. This version is brief and is
administered in three different conditions: (1) free-drawn
clock condition, in which the subjects were provided with a
blank sheet and they were asked to draw all aspects of the
clock; (2) pre-drawn clock condition, in which the a pre-
drawn circle is on a A4 sheet; (3) and the examiner pre-
drawn clock condition, in which the subjects are provided
with a pre-drawn clock and only the hands are missing;
they are asked to set the hands at different times (i.e., 8:20,
11:10, 3 o’clock). Further investigations should consider
both our scoring system and the one proposed by Freedman
et al. [39] with its Italian normative scores in order to
compare their accuracy to detect mild cognitive decline.
Compliance with ethical standards
Conflict of interest The authors report no conflict of interests.
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