Use of the clock-drawing test in a hospice population

Abstract

Background : Cognitive impairment is common in patients with advanced disease and has significant implications for the patient, their carers and hospice staff. The effectiveness of screening tools is limited by a number of factors. The clock-drawing test (CDT) has performed well in other settings but has rarely been studied in the hospice setting. Aim : To assess the performance of the CDT in a hospice population. Methods : Consecutive admissions to a large hospice over three months were assessed using the CDT, the abbreviated mental test score and brief tests of attention and memory function. Results : One-hundred and nine eligible patients were admitted and 77% took part. Thirty per cent were cognitively impaired. The CDT had a sensitivity of 0.92, a specificity of 0.73 and a negative predictive value of 0.95. No patient refused to complete it. Conclusions : The CDT performs well as a screening tool for cognitive impairment in a hospice population. Palliative Medicine 2007; 21: 559—565

Keywords

clock-drawing test cognitive impairment palliative medicine

Get full access to this article

View all access options for this article.

References

Barbato M. , Rodriguez PJ Thiamine deficiency in patients admitted to a palliative care unit . Palliat Med 1994; 8(4): 320—4 .

Klepstad P. , Hilton P. , Moen J. , Fougner B. , Borchgrevink PC , Kaasa S. Self-reports are not related to objective assessments of cognitive function and sedation in patients with cancer pain admitted to a palliative care unit . Palliat Med 2002; 16(6): 513—9 .

Radbruch L. , Sabatowski R. , Loick G. et al. Cognitive impairment and its influence on pain and symptom assessment in a palliative care unit: development of a Minimal Documentation System . Palliat Med 2000; 14(4): 266—76 .

Pereira J. , Hanson J. , Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer . Cancer 1997; 79(4): 835—42 .

Bruera E. , Spachynski K. , MacEachern T. , Hanson J. Cognitive failure in cancer patients in clinical trials . Lancet 1993; 341(8839): 247—8 .

Sarhill N. , Walsh D. , Nelson KA , LeGrand S. , Davis MP Assessment of delirium in advanced cancer: the use of the bedside confusion scale . Am J Hosp Palliat Care 2001; 18(5): 335—41 .

Caraceni A. , Nanni O. , Maltoni M. et al. Impact of delirium on the short term prognosis of advanced cancer patients. Italian Multicenter Study Group on Palliative Care . Cancer 2000; 89(5): 1145—9 .

Gagnon P. , Allard P. , Masse B. , DeSerres M. Delirium in terminal cancer: a prospective study using daily screening, early diagnosis, and continuous monitoring . J Pain Symptom Manage 2000; 19(6): 412—26 .

Lawlor PG , Gagnon B. , Mancini IL et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study . Arch Intern Med 2000; 160(6): 786—94 .

10.

Breitbart W. , Rosenfeld B. , Roth A. , Smith MJ , Cohen K. , Passik S. The Memorial Delirium Assessment Scale . J Pain Symptom Manage 1997; 13(3): 128—37 .

11.

Hjermstad M. , Loge JH , Kaasa S. Methods for assessment of cognitive failure and delirium in palliative care patients: implications for practice and research . Palliat Med 2004; 18(6): 494—506 .

12.

Pearse H. , Nicholson L. , Bennett M. Falls in hospices: a cancer network observational study of fall rates and risk factors . Palliat Med 2004; 18(5): 478—81 .

13.

Henderson M. Mental health needs. In Oliviere DMB , ed. Death, dying and social differences. London : Oxford University Press , 2004.

14.

Inouye SK , Foreman MD , Mion LC , Katz KH , Cooney LM, Jr. Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings . Arch Intern Med 2001; 161(20): 2467—73 .

15.

Bruera E. , Miller L. , McCallion J. , Macmillan K. , Krefting L. , Hanson J. Cognitive failure in patients with terminal cancer: a prospective study . J Pain Symptom Manage 1992; 7(4): 192—5 .

16.

Breitbart W. , Strout D. Delirium in the terminally ill . Clin Geriatr Med 2000; 16(2): 357—72 .

17.

Inouye SK , van Dyck CH , Alessi CA , Balkin S. , Siegal AP , Horwitz RI Clarifying confusion: the confusion assessment method. A new method for detection of delirium . Ann Intern Med 1990; 113(12): 941—8 .

18.

Trzepacz PT , Baker RW , Greenhouse J. A symptom rating scale for delirium . Psychiatry Res 1988; 23(1): 89—97 .

19.

Williams MA , Ward SE , Campbell EB Confusion: testing versus observation . J Gerontol Nurs 1988; 14(1): 25—30 .

20.

Folstein MF , Robins LN , Helzer JE The Mini-Mental State Examination . Arch Gen Psychiatry 1983; 40(7): 812 .

21.

Anthony JC , LeResche L. , Niaz U. , von Korff MR , Folstein MF Limits of the `Mini-Mental State' as a screening test for dementia and delirium among hospital patients . Psychol Med 1982; 12(2): 397—408 .

22.

Smith MJ , Breitbart WS , Platt MM A critique of instruments and methods to detect, diagnose, and rate delirium . J Pain Symptom Manage 1995; 10(1): 35—77 .

23.

Schwamm LH , Van Dyke C. , Kiernan RJ , Merrin EL , Mueller J. The neurobehavioral cognitive status examination: comparison with the cognitive capacity screening examination and the mini-mental state examination in a neurosurgical population . Ann Intern Med 1987 ; 107(4): 486—91 .

24.

Hodkinson HM Evaluation of a mental test score for assessment of mental impairment in the elderly . Age Ageing 1972; 1(4): 233—8 .

25.

Sahadevan S. , Lim PP , Tan NJ , Chan SP Diagnostic performance of two mental status tests in the older chinese: influence of education and age on cut-off values . Int J Geriatr Psychiatry 2000; 15(3): 234—41 .

26.

R.C. Psych. Standardised assessment scales for elderly people. London : Royal College of Physicians of London , 1992.

27.

Power D. , Kelly S. , Gilsenan J. et al. Suitable screening tests for cognitive impairment and depression in the terminally ill—a prospective prevalence study . Palliat Med 1993; 7(3): 213—8 .

28.

Goodglass Hke. The assessment of aphasia and related disorders. Philadelphia : Lea and Febiger , 1983.

29.

Heinik J. , Solomesh I. , Lin R. et al. Clock Drawing Test-Modified and Integrated Approach (CDT-MIA): description and preliminary examination of its validity and reliability in dementia patients referred to a specialized psychogeriatric setting . J Geriatr Psychiatry Neurol 2004; 17(2): 73—80 .

30.

Moretti R. , Torre P. , Antonello RM , Cazzato G. , Bava A. Ten-Point Clock Test: a correlation analysis with other neuropsychological tests in dementia . Int J Geriatr Psychiatry 2002; 17(4): 347—53 .

31.

Manos PJ Ten-point clock test sensitivity for Alzheimer's disease in patients with MMSE scores greater than 23 . Int J Geriatr Psychiatry 1999; 14(6): 454—8 .

32.

Shulman KI

Clock-drawing: is it the ideal cognitive screening test?

Int J Geriatr Psychiatry 2000; 15(6): 548—61 .

33.

Manos PJ The utility of the ten-point clock test as a screen for cognitive impairment in general hospital patients . Gen Hosp Psychiatry 1997; 19(6): 439—44 .

34.

Shulman Ksr , Silver I. The challenge of time: clock drawing and cognitive function in the elderly . Int J Geriatr Psychiatry 1986; 1: 135—40 .

35.

Brodaty H. , Moore CM The Clock Drawing Test for dementia of the Alzheimer's type: a comparison of three scoring methods in a memory disorders clinic . Int J Geriatr Psychiatry 1997; 12(6): 619—27 .

36.

Seigerschmidt E. , Mosch E. , Siemen M. , Forstl H. , Bickel H. The clock drawing test and questionable dementia: reliability and validity . Int J Geriatr Psychiatry 2002; 17(11): 1048—54 .

37.

Ainslie NK , Murden RA Effect of education on the clock-drawing dementia screen in non-demented elderly persons . J Am Geriatr Soc 1993; 41(3): 249—52 .

38.

Kirby M. , Denihan A. , Bruce I. , Coakley D. , Lawlor BA The clock drawing test in primary care: sensitivity in dementia detection and specificity against normal and depressed elderly . Int J Geriatr Psychiatry 2001; 16(10): 935—40 .

39.

Parker C. , Philp I. Screening for cognitive impairment among older people in black and minority ethnic groups . Age Ageing 2004; 33(5): 447—52 .

40.

Shulman Kgd , Cohen C. , Zucchero C. Clock-drawing and dementia in the community: a longitudinal study . Int J Geriatr Psychiatry 1993; 8: 487—96 .

41.

Borson S. , Scanlan J. , Brush M. , Vitaliano P. , Dokmak A. The mini-cog: a cognitive `vital signs' measure for dementia screening in multi-lingual elderly . Int J Geriatr Psychiatry 2000; 15(11): 1021—7 .

42.

Huntzinger JA , Rosse RB , Schwartz BL , Ross LA , Deutsch SI Clock drawing in the screening assessment of cognitive impairment in an ambulatory care setting: a preliminary report . Gen Hosp Psychiatry 1992; 14(2): 142—4 .

43.

Hearn J. , Higginson IJ Development and validation of a core outcome measure for palliative care: the palliative care outcome scale. Palliative Care Core Audit Project Advisory Group . Qual Health Care 1999; 8(4): 219—27 .

44.

Stillman MJ , Rybicki LA The bedside confusion scale: development of a portable bedside test for confusion and its application to the palliative medicine population . J Palliat Med 2000; 3(4): 449—56 .