CLOCK-DRAWING TEST

AND MINI MENTAL

STATE EXAMINATION
Presented By:
Iyan meyasdi
The clock-drawing test is a good screening test
for dementia and cognitive dysfunction with the
possible exception of cases of very early
Alzheimer's disease. The test has a high
correlation with the MMSE and other tests of
cognitive dysfunction. Its value in diagnosing
unilateral neglect and focal brain damage
requires further study. It is easy to administer, is
not threatening to the patient and takes very
little time. It is easy to document graphically in
clinical records and it can be used to document
deterioration over time in dementia patients.
Normal clock-drawing ability reasonably excludes
cognitive impairment.
The clock-drawing test is used for screening for
cognitive impairment and dementia and as a
measure of spatial dysfunction and neglect. It
was originally used to assess visuo-constructive
abilities but we know that abnormal clock
drawing occurs in other cognitive impairments.
Doing the test requires verbal understanding,
memory and spatially coded knowledge in
addition to constructive skills. Education, age and
mood can influence the test results, with subjects
of low education, advanced age and depression
performing more poorly.
Different ways of performing the
clock-drawing test

Clock drawing can be performed in different ways and the
scoring also varies. The subject is presented with a white
paper with the instructions to draw a clock. There is no
time limit. In the free-drawn method, the subject is asked
to draw a clock from memory. In the pre-drawn method,
the subject is presented with a circular contour and is
expected to draw in the numbers on the clock face.
Sometimes the subject is asked to draw the hands at a
fixed time, often 10 past 11, but in many cases the hands
are excluded. In still another method the subject is asked
only to set the hands at a fixed time on a pre-drawn clock,
complete with contour and numbers
traced a four-inch diameter circle in the
chart and then asked the patient to write in
the numbers that appear in the face of a
clock. When they had finished that task,
asked them to make the clock read ten
minutes after 11, consciously avoiding
mention of the hands of a clock. This is the
entire procedure for the administration of the
10-point clock test (Manos and Wu, 1994)
produced a clear plastic template, four inches in diameter
and divided into eighths, both to trace the circle and score
the test.
To score, the clock is divided into eighths, beginning with a
line through the number 12 and the center of the circle. (If
the 12 is missing, its position is assumed to be
counterclockwise from the 1 at a distance equal to that
between the 1 and 2.) Any straight edge may be used to
divide the clock into eighths. This is accomplished more
quickly by placing the clear, flat plastic template over the
circle with a line through the number 12.
One point each is given for the numbers 1, 2, 4, 5, 7, 8,
10, and 11 if at least half the area of the number is in the
proper octant of the circle relative to the number 12. One
point each is given for an obvious short hand pointing at
the 11 and an obvious long hand pointing to the 2. The
difference in the length of the hands must be obvious at a
glance.
A score of 10 suggests that cognitive
impairment (CI) is unlikely, although
isolated short-term memory
impairment such as that seen with
carbon monoxide poisoning may be
missed. A score of eight or nine must
be interpreted clinically. However, a
score of less than eight indicates
almost CI, and a score of less than
five indicates prominent impairment.
Mini mental State examination
Effective screening for cognitive
impairment requires assessment of
multiple aspects of mental
functioning, including orientation,
short-term memory, receptive and
expressive language ability,
attention, and visual-spatial ability.
Questions (Total of 30 points)

- Orientation (10 points)
Patient identifies time and place
- Registration (3 points) and Recall (3
points)
Patient recalls objects at 1 and 5 minutes
- Attention and Calculation (5 points)
Patient spells a word backwards
- Language (9 points)
Tests processing language

Interpretation of Mini-mental State Score (Maximum: 30)

Normal score: 24 or higher
Educational and Age Norms
Fourth Grade Education
Ages 18 to 69: Median MMSE Score 22-25
Ages 70 to 79: Median MMSE Score 21-22
Age over 79: Median MMSE Score 19-20
Eighth Grade Education
Ages 18 to 69: Median MMSE Score 26-27
Ages 70 to 79: Median MMSE Score 25
Age over 79: Median MMSE Score 23-25
High School Education
Ages 18 to 69: Median MMSE Score 28-29
Ages 70 to 79: Median MMSE Score 27
Age over 79: Median MMSE Score 25-26
College Education
Ages 18 to 69: Median MMSE Score 29
Ages 70 to 79: Median MMSE Score 28
Age over 79: Median MMSE Score 27