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Dr Hala Samir Sweed M.B.B.Ch, MSC, MD Consultant Geriatrician Associate Professor of Geriatrics and Gerontology Faculty of Medicine- Ain Shams University – EGYPT Member of IAGG
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Clock drawing test (CDT) has well established correlations with other cognitive tests including the Mini Mental Status Exam (MMSE)
CDT has consistently shown general sensitivity rates of 81- 95%; an above-average percentage for cognitive screening tools
Schramm et al, 2002
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Subjects with VaD have been found to executive functioning considerably more deteriorated than those with AD.
Inzitari & Pantoni , 1998
Examples of ECFs include goal selection, planning, motor sequencing, and selective attention. All are required by clock drawing.
Royall et al,1998
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Thus, patients with VaD might be expected to have poorer performance in CDT. However, studies have shown controversy results ;
Wiechmann, et al, (2010)
Witoonpanich, et al, (2010)
Matioli and Caramelli, (2010)
Heinik, et al, (2002)
Moretti et al, (2002)
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DT-MRI is a promising technique to explore the anatomical basis of human cognition and its disorders
Bozzali et al, (2002) Chen et al., (2009) Stahl et al, (2007) Sugihara et al, (2004) Kantarci et al, (2001)
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CDT may correlate with radiographic findings of cerebral structures identified as having a role in executive function.
Samton et al, (2005)
Tranel et al, (2008)
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To assess the clock drawing testing (CDT) and diffusion tensor magnetic resonance imaging (DT-MRI) differences between probable Alzheimer’s dementia (AD) and vascular dementia (VaD) and the CDT correlation with the DT-MRI .
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Study Population
Elderly patients presenting at the Geriatric outpatient clinic
Study Duration;
6months
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Tools of assessment
Full medical and personal history.
Functional assessment------------Activities of Daily Living questionnaire (ADL).
Mood assessment----------------
Geriatric depression scale 15 items (GDS-15).
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Tools of assessment
Cognitive assessment------------
DSM-IV criteria
Mini-mental status examination (MMSE)
Hachinski ischemic index (HIS)
The Clock Drawing Test (CDT) (Shulman et al, 1993)
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Tools of assessment
Laboratory investigations
DT- MRI------30 elderly
Apparent diffusion coefficient (ADC)
Fractional anisotropy (FA)
15 ROIs
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92 elderly
89 elderly
completed the
study
58.4% females
(n=52/89)
41.6% males
(n=37/89)
3 excluded
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Controls
n=49
Alzheimer's D
n= 25
Vascular Dementia
n=15
Age 64.94±4.77 74.40±4.71
*t=8.103 p=0.000
**t=1.572 p=0.124
72.10±4.25
*t=5.185 p=0.000
Gender F/ M 26/23
53.1%/ 46.9%
19/6
76%/ 24%
*X2=0.078 p=0.047
**X2=0.089 p=0.062
7/8
46.7%/ 53.3%
*X2=0.771 p=0.445
Years of Education 7.84± 4.79 7.76± 4.19
*t=0.068 p=0.946
**t=0.539 p=0.593
7.00± 4.54
*t=0.599 p=0.552
ADL
Dependent
Assisted
Independent
7 14.3%
11 22.4%
31 63.3%
7 28%
15 60%
3 12%
*X2=17.758 p=0.000
**X2=0.640 p=0.726
3 20%
9 60%
3 20%
*X2=9.469 p=0.009
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Controls
n=49
Alzheimer's D
n= 25
Vascular Dementia
n=15
GDS 2.71±2.10 3.48± 2.31
*t=1.433 p=0.156
**t=0.592 p=0.558
3.93± 2.40
*t=1.901 p=0.062
MMSE 27.37±1.64 15.90±2.91
*t=21.765 p=0.000
**t=1.927 p=0.061
17.73±3.01
*t=16.057 p=0.000
Hachiniski score 2.04± 0.84
**t=25.300 p=0.000
9.00± 0.85
CDT 1.18±0.39 4.16±0.69
*t=23.757 p=0.000
**t=3.280 p=0.002
5.00±0.93
*t=23.152 p=0.000
Spacing error 5 20%
**X2=11.111 p=0.001
11 73.3%
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A B Figure (1) showing CDT of two patients A (VaD) and B (AD) both
have a MMSE score of 21/30, with evidence of spacing error in VaD’s clock drawing.
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Controls
n=10
Alzheimer's D
n= 10
Vascular Dementia
n=10
Age 70.20±5.73 71.60±3.06
*t=0.681 p=0.504
**t=0.278 p=0.784
72.00±3.37
*t=0.856 p=0.403
Gender F/ M 7/3
70%/ 30%
8/2
80%/ 20%
*X2=0.268 p=0.605
**X2=0.966 p=0.326
6/4
60%/ 40%
*X2=0.220 p=0.639
Years of Education 10.60± 5.08 7.70± 2.63
*t=1.603 p=0.126
**t=0.066 p=0.948
7.60± 4.00
*t=1.466 p=0.160
ADL
Dependent
Assisted
Independent
0 0%
1 10%
9 90%
4 40%
5 50%
1 10%
*X2=13.067 p=0.001
**X2=1.865 p=0.394
3 30%
7 70%
0 0%
*X2=16.500 p=0.000
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Controls
n=10
Alzheimer's D
n= 10
Vascular Dementia
n=10
GDS 3.00±2.54 3.50± 2.79
*t=0.418 p=0.681
**t=0.173 p=0.0.865
3.30± 2.36
*t=0.274 p=0.787
MMSE 27.90±1.64 16.80±2.35
*t=13.320 p=0.000
**t=1.454 p=0.163
18.60±3.13
*t=8.766 p=0.000
Hachiniski score 1.90± 0.99
**t=18.515 p=0.000
8.80± 0.63
CDT 1.30±0.48 3.90±0.74
*t=9.303 p=0.000
**t=2.242 p=0.038
4.80±1.03
*t=9.707 p=0.000
Spacing error 2 20%
**X2=5.300 p=0.021
7 70%
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Figure (2) showing the DTI-MRI cuts of 3 patients A) A subject with normal cognitive function, B) patient with propable AD and C) a patient with VaD. The ROI being placed at the medial temporal lobe and figures show high ADC and reduced FA in patients with dementia compared to the control.
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Normal AD
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Normal VaD
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AD VaD
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AD VaD
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CDT differs among VaD and AD with a range of radiological correlations.
Larger studies are needed to confirm the use of CDT as a discriminative tool between VaD and AD.
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DT-MRI is a sensitive and discriminative technique for the evaluation of patients with cognitive impairment including probable AD and VaD
Reference ranges need to be set through larger studies.
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