title: The accuracy of the Clock Drawing Test compared to that of standard screening tests for Alzheimer's disease: results from a study of Brazilian elderly with heterogeneous educational backgrounds.
abstract: BACKGROUND
  Although the Clock Drawing Test (CDT) is the second most used test in the world for the screening of dementia, there is still debate over its sensitivity, specificity, application and interpretation in dementia diagnosis. This study has three main aims: to evaluate the sensitivity and specificity of the CDT in a sample composed of older adults with Alzheimer's disease (AD) and normal controls; to compare CDT accuracy to the that of the Mini-mental State Examination (MMSE) and the Cambridge Cognitive Examination (CAMCOG); and to test whether the association of the MMSE with the CDT leads to higher or comparable accuracy as that reported for the CAMCOG.
  
  
  METHODS
  Cross-sectional assessment was carried out for 121 AD and 99 elderly controls with heterogeneous educational levels from a geriatric outpatient clinic who completed the Cambridge Examination for Mental Disorder of the Elderly (CAMDEX). The CDT was evaluated according to the Shulman, Mendez and Sunderland scales.
  
  
  RESULTS
  The CDT showed high sensitivity and specificity. There were significant correlations between the CDT and the MMSE (0.700-0.730; p < 0.001) and between the CDT and the CAMCOG (0.753-0.779; p < 0.001). The combination of the CDT with the MMSE improved sensitivity and specificity (SE = 89.2-90%; SP = 71.7-79.8%). Subgroup analysis indicated that for elderly people with lower education, sensitivity and specificity were both adequate and high.
  
  
  CONCLUSIONS
  The CDT is a robust screening test when compared with the MMSE or the CAMCOG, independent of the scale used for its interpretation. The combination with the MMSE improves its performance significantly, becoming equivalent to the CAMCOG.
authors.affiliation: Gerontology Division, University of Campinas, São Paulo, Brazil. ivan.aprahamian@terra.com.br
authors.forename: Ivan
authors.initials: I
authors.lastname: Aprahamian
authors.forename: José Eduardo
authors.initials: JE
authors.lastname: Martinelli
authors.forename: Anita Liberalesso
authors.initials: AL
authors.lastname: Neri
authors.forename: Mônica Sanches
authors.initials: MS
authors.lastname: Yassuda
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000544:Alzheimer Disease / Q000175:diagnosis* / Q000453:epidemiology; D001938:Brazil / Q000453:epidemiology; D003072:Cognition Disorders / Q000175:diagnosis* / Q000453:epidemiology*; D004522:Educational Status; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods*; D009483:Neuropsychological Tests; D012720:Severity of Illness Index