The Clock-Drawing Test

by Dr.Peter Braunberger (2001)

Setting and scoring the test

Three easy steps
Scoring
Why do test?
Sensitive and specific
Example clock
References
Appendix of Scoring Methods
Mendez et al. 1992
Lam et al 1998
Wolf-Klein et al. 1989
Shua-Haim et al. 1996
Shulman et al. 1986
Sunderland et al. 1983
Setting and Scoring the Test
There are numerous versions of the clock-drawing test. They all involve asking the patient to draw
the face of a clock. Variations include providing a blank piece of paper or a paper with a predrawn (often 10 cm diameter) circle and asking the patient to draw the face of a clock. Further
questions from the patients may be politely deferred by repeating the request to draw the face of a
clock. Most variations of the test also include asking the patient to draw in the arms to denote
certain time. Many times have been used including, 3:00, 8:40, 2:45 and so on. They time 11:10
has been suggested as useful because of the distraction of "pull" of the numeral ten on the clock
when setting a time. Generally there is no time limit to the test, but the test usually takes only one
to two minutes.
3 Easy Steps
1. Provide patient with a piece of paper with a pre-drawn circle of approximately 10 cm in
diameter.
2. Indicate that the circle represents the face of a clock and ask the patient to put in the
numbers so that it looks like a clock.
3. Ask the patient to add arms so that the clock indicates the time "ten minutes after eleven."
Scoring

There are a number of variations on scoring the clock, more than variations in administering the
test itself. Most scoring systems are highly correlated with well-established measures including the
MMSE, Dementia Rating Scale and the Global Deterioration Scale.
Perhaps the quickest scoring technique involves dividing the clock into four quadrants and
counting the numbers in the correct quadrant. More complex assessments include evaluating 20
traits, or categorizing errors conceptually.
Common methods of scoring are as follows:
Sulman et al 1986
Sunderland et al 1989
Wolf-Klein et al 1989
Mendez et al 1992
Shua-Haim et al 1996
Lam et al 1998
Why do the Test?
The clock has been proposed as a quick screening test for cognitive dysfunction secondary to
dementia, delirium, or a range of neurological and psychiatric illnesses. Many health care workers
are faced with questions regarding the function and safety of patients in differing environments. A
quick screening for cognitive function may contribute an overall assessment of required
investigations and resources for the patient.
The clock drawing test may complement other quick screening tests including the MMSE and is a
component of the "7 Minute Neurocognitive Screening Battery" (Solomon et al 1998).
The strength and weakness of the clock-drawing test lies in the number of cognitive, motor and
perceptual functions required simultaneously for successful completion. orientation,
conceptualization of time, visual spatial organization (Lam et al 1998) memory and executive
function (Estaban-Santillan et al 1998), auditory comprehension, visual memory, motor
programming, numerical knowledge, semantic instruction, inhibition of distracting stimuli,
concentration and frustration tolerance (Shulman 2000) have all been highlighted as contributing
to the successful clock. Royall (1996) suggests the executive function required for clock-drawing
involves "control functions which guide complex goal-directed behaviour in the face of novel and
irrelevant or ambiguous environmental cues", and that similar demands are shared by
independent living skills.
The completely normal clock is therefore a suggestion that a number of functions are intact and
contributes to the weight of evidence that the patient may, for example, be able to continue
independently. Alternatively, a grossly abnormal clock, is an important indicator of potential
problems warranting further investigation or resource allocation.

While the grossly abnormal clock demands immediate attention, questions regarding the
importance of minor errors remain. Shulman (2000) suggests that serial clock drawing can be
used to follow a progressive dementing process, or recovery from a toxic delirium. EstebanSantillan et al (1998) suggest that minor clock errors are suggestive of a dementing process. They
also highlight the placement of the arms as the most abstract feature of clock drawing, and
therefore useful in early dementing processes.
Clock errors may be divided into categories including visuo-spatial, perseveration, grossly
disorganized. Common errors in Alzheimer's disease include perseveration, counter-clockwise
numbering, absence of numbers and irrelevant spatial arrangement. Errors following stroke may
reflect spatial neglect, hemianopsia and sensory loss, in addition to errors suggestive of cognitive
dysfunction (Freidman 1991). Lam et al (1998) were unable to differentiate Alzheimer's Disease
and Multi-infarct dementia according to clock errors.
A variety of psychiatric conditions contribute potentially to abnormal clock-drawing, (Gruber et al
1997). Lee & Lawlor report on a subset of patients whose clock drawings improved significantly
when treated for depression. Cognitive decline and psychotic state both contributed to poor scores
in a clock-drawing test of elderly patients with a long-standing diagnosis of schizophrenia (Heinik
et al 1997).
Sensitivity and specificity, likelihood ratio and positive predictive value have all been used to
measure the potential value of the clock-drawing test as a screening tool (Shulman 2000). These
vary with the score on the clock drawing test. Sensitivity (i.e. few false negatives) to dementia
across many studies range from 75 to 92 percent depending on the population being assessed, and
averaged 85%. Specificity (ie. few false positives) 65 to 96 percent with an average of 85%, however
clock errors may predict many conditions in addition to dementia and it is important to maintain
a wide differential diagnosis with clock errors.
References
Borson, S. et al. 1999. The clock drawing test: utility for dementia detection in multiethnic elders.
Journal of Gerontology Medical Sciences 54A:M534-M540.
Esteban-Santillan, C. et al. 1998. Clock drawing test in very mild Alzheimer's Disease. Journal of
the American Geriatrics Society 46:1266-1269.
Friedman, PJ. 1991. Clock drawing in acute stroke. Age and Ageing. 20:140-145.
Gruber et al. 1996. A comparison of the clock drawing test and the Pfeiffer Short Portable Mental
Status Questionnaire in a geopsychiatry clinic. International Journal of Geriatric Psychiatry.
12:526-532.

Heinik, J. et al. 1997. Clock drawing test in elderly schizophrenia patients. International Journal
of Geriatric Psychiatry. 12:653-655.
Heinik, J. et al. 2000. Comparison of a clock drawing test in elderly schizophrenic and Alzheimer
disease patients: A preliminary study. International journal of geriatric Psychiatry. 15:638643.
Lam, LCW. et al. 1998. Clock-face drawing, reading and setting test in the screening of dementia
in Chinese elderly adults. Journal of Gerontology. 53B:353-357.
Lee, L., and Lawlor, BA. 1995. State dependent nature of the clock-drawing task in geriatric
depression. Journal of the American Geriatric Society. 43:796-798.
Mendez et al. 1992. Development of scoring criteria for the clock drawing task in Alzheimer's
Disease. Journal of the American Geriatric Society. 40:1095-1099.
Royall, DR. 1996. Comments of the executive control of clock-drawing. Journal of the American
Geriatric Society. 44:218-219.
Shua-Haim et al. 1996. A simple scoring system for clock-drawing in patients with Alzheimer's
disease. Journal of the American Geriatric Society. 44:335.
Shulman, K.I. 2000. Clock-drawing: Is it the ideal cognitive screening test? International Journal
of Geriatric Psychiatry. 15:548-561.
Solomon et al. 1998. A seven minute neurocognitive screening battery highly sensitive to
Alzheimer's disease. Archives of Neurology. 55:349-355.
Sunderland, T. et al. 1989. Clock drawing in Alzheimer's Disease: A novel measure of dementia
severity. Journal of the American Geriatric Society. 37:725-729.
Wolf-Klein, G.P. et al. 1989. Screening for Alzheimer's Disease by clock drawing. Journal of the
American Geriatric Society. 37:730-734.
Appendix: Scoring Methods
Mendez et al. 1992. Clock Drawing Interpretation Scale (CDIS) with the time "ten minutes past
eleven."
1. There is an attempt to indicate a time in any way.
2. All marks or items can be classified as either part of a closure figure, a hand or a symbol for
clock numbers.
3. There is a totally closed figure without gaps ("the closure figure"). Score only if symbols for
clock numbers are present.

4. A "2" is present and pointed out in some way for the time.
5. Most symbols are distributed as a circle without major gaps.
6. Three or more clock quadrants have one or more appropriate numbers per respective
quadrant.
7. Most symbols are ordered in a clockwise fashion.
8. All symbols are totally within a closure figure.
9. An "11" is present and is pointed out in some way for time.
10. All numbers 1 to 12 are present.
11. There are no repeated or duplicated number symbols.
12. There are no substitutions for Arabic or Roman numerals.
13. The numbers do not go beyond the number 12.
14. All symbols lie about equally adjacent to a closure figure edge.
15. Seven or more of the same symbol type are ordered sequentially. Score only if one or more
hands are present.
16. All hands radiate from the direction of a closure figure's center.
17. One hand is visibly longer than another hand.
18. There are two distinct and separable hands.
19. All hands are totally within a closure figure.
20. There is an attempt to indicate a time with one or more hands.
Lam et al. 1998. Scoring criteria for clock drawing test.
Score
0
1
2
3
4
5

Description of clock
Correct time with normal spacing.
Slight impairment in spacing of lines or numbers.
Noticeable impairment in line spacing.
Incorrect spacing between numbers with subsequent inappropriate denotation of time.
Obvious errors in time denotation (arms misplaced, numbers in wrong place)
Abnormal clock-face drawing with inaccurate time denotation (eg. rever sal of numbers,
perseveration beyond twelve, misplaced numbers, drawing only to one side, omitting
most numbers)
6
Abnormal clock face drawing with inaccurate time denotation (eg reversal of numbers,
perseveration
beyond twelve, misplaced numbers and drawing to one side and omitting most
numbers).
7
A recognizable attempt to draw a clock face but no clear denotation of time.
8
Some evidence that a clock face is drawn.
9
Minimal evidence that a clock face is drawn.
10
No reasonable attempt to drawing a clock face (exclude gross visual disturbance,
hemiplegia and
severe psychotics state).

Wolf-Klein et al. 1989.

Clock Type Description
X
Normal
IX
almost normal except for number
VIII
almost normal except for spacing
VII
very inappropriate spacing
VI
perseveration
V
absence of numbers
IV
counter clockwise rotation
III
other
II
irrelevant spatial arrangement
I
irrelevant figures
Shua-Haim et al. 1996. Simple scoring system
Award one point for each of the following:
Approximate drawing of the clock face
Presence of numbers in sequence
Correct spacial arrangement of numbers
Presence of clock hands
Hands showing approximately the correct time
Hands depicting the exact time
Shulman et al. 1986. Classification of clock errors with the time
1. Visual spatial
a. Mildly impaired spacing of times
b. Draws lines outside of circle
c. Turns page while writing numbers so that some numbers appear upside down
d. Draws in lines to orient spacing.
2. Error in denoting time as 3 o'clock
a. Omits minute hand
b. Draws single line from 3 to 12
c. Writes words 3 o'clock
d. Writes number three again
e. Circles or underlines 3
f. Unable to indicate 3 o'clock
3. Visual spatial
a. Moderately impaired spacing of lines

b. Omits number
c. Perseveration
i. Repeats circle
ii. Continues on past 12 to 13, 14, 15 etc
iii. Counter-clockwise
iv.
Dysgraphia
4. 4. Severely disorganized spacing
a. Confused time, writes in minutes, times of day, months or seasons
b. Draws picture of human face
c. Writes words "clock"
5. Unable to make reasonable attempt at clock
a. Exclude severe depression or psychotic state)
Sunderland et al. 1983. A PRIORI criteria for evaluating clock drawings.
10-6 Drawing of clock face with number and circle generally intact
10 Hands in correct position (ie. Hours hand approaching 3 o'clock)
9 Slight errors in placement of hands.
8 More noticeable errors in placement of hour and minute hands
7 Placement of hands is significantly off course
6 Inappropriate use of clock hands (ie. use of digital display or circling numbers despite
repeated instructions)
5-1 Drawing of clock face with circle and numbers is NOT intact
5 Crowding of numbers at one end of the clock or reversal of numbers. Hands may still be
present in some fashion.
4 Further distortion of number sequence. Integrity of clock face is now gone (ie. numbers missing
or placed outside of boundaries of the clock face)
3 Numbers and clock face no longer obviously connected in the clock drawing. Hands are not
present.
2 Drawing reveals some evidence of instructions being received but only vague representation of
a clock.
1 Either no attempt or an uninterpretable effort is made.

Sensitivity and Specificity

Sensitivity = (true positive)/(true positive + false negative)
Specificity = (true negative)/(true negative + false positive)