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Original article
Assessment of the diagnostic accuracy and discriminative validity of the Clock Drawing and Mini-Cog tests in detecting cognitive impairment
Evaluación de la utilidad diagnóstica y validez discriminativa del Test del Reloj y del Mini-Cog en la detección del deterioro cognitivo
C. Carnero-Pardoa,
Corresponding author
ccarnero@neurocenter.es

Corresponding author.
, I. Rego-Garcíab, J.M. Barrios-Lópezb, S. Blanco-Maderab, R. Calle-Calleb, S. López-Alcaldea, R.M. Vílchez-Carrillob
a FIDYAN Neurocenter, Granada, Spain
b Servicio de Neurología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Subjective cognitive complaints and memory loss constitute a frequent reason for consultation with primary care and referral to the neurology department&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Initial assessment and follow-up of these patients requires the use of valid cognitive assessment tools that are brief enough to be administered during consultations&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The Mini&#8211;Mental State Examination &#40;MMSE&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> currently the most frequently used cognitive assessment tool&#44; is rapidly losing supporters due to numerous limitations&#44; including its cost&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and was even excluded from the third version of the Alzheimer Disease Centers&#8217; Neuropsychological Test Battery&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The Montreal Cognitive Assessment&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in contrast&#44; is increasingly popular&#46; It includes multiple domains&#44; but has an even longer administration time than the MMSE&#44; which limits its use in general consultations and particularly in primary care&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The clock drawing test &#40;CDT&#41;&#44; one of the oldest and most widely used brief cognitive tests&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> is considered by some authors to be the ideal cognitive screening test due to its simplicity and brevity&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; it does present some limitations&#58; it does not explicitly evaluate episodic memory&#59; it requires a minimum level of graphomotor skills &#40;which may be problematic for illiterate individuals or those with a low level of education&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#59; it does not have a simple&#44; standardised grading system<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#59; and its diagnostic accuracy is limited&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The Mini-Cog&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> a simple&#44; quick-to-administer instrument&#44; aims to address some of the limitations of the CDT&#58; it includes a 3-item free recall task and a simplified clock-drawing task&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> It has been validated in multiple settings &#40;community&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> primary care&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> specialised clinics<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#41; and in numerous languages &#40;available at <a href="https://mini-cog.com/mini-cog-in-other-languages/">https&#58;&#47;&#47;mini-cog&#46;com&#47;mini-cog-in-other-languages&#47;</a>&#41;&#46; Furthermore&#44; there are 15 versions of the Mini-Cog&#44; which differ in the set of items the patient has to recall &#40;5 options&#41; and the time to which the clock has to be set &#40;3 options&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The Mini-Cog is currently one of the most widely recommended dementia screening tools for primary care and general consultations&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;22</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The Mini-Cog has been used in some studies conducted in Spanish-speaking countries&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> although no formal evaluation of the Spanish-language version has been conducted to date&#46; In Spain&#44; one study did evaluate the test&#8217;s diagnostic usefulness&#44; calculating results retrospectively by adding together scores for CDT drawings and the MMSE recall task&#44; which had previously been administered independently&#59; however&#44; the Mini-Cog was not actually administered&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The purpose of this study was to formally evaluate the discriminant validity and diagnostic usefulness of the CDT and the Mini-Cog for identifying individuals with cognitive impairment in a large sample of patients attended at the neurology clinic&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted a cross-sectional study including all patients attended between March and September 2018 at a neurology clinic specialising in cognitive and behavioural neurology&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">For patients attended on more than one occasion during the study period&#44; we only included the data corresponding to the last evaluation&#44; as these were considered to be the most reliable from a diagnostic viewpoint&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Cognitive assessment</span><p id="par0045" class="elsevierStylePara elsevierViewall">All patients underwent a brief cognitive assessment including the Mini-Cog&#44; the CDT&#44; and the Fototest&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> regardless of the reason for consultation&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All patients attended due to subjective or informant-reported memory complaints and&#47;or behavioural alterations&#44; or those scoring below the 10th percentile on the Fototest&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> underwent a thorough cognitive assessment including orientation &#40;temporal&#44; spatial&#44; and personal&#41;&#44; attention &#40;forward and backward digit span&#41;&#44; memory &#40;learning&#44; free recall&#44; and recognition of the CERAD word list<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#41;&#44; language &#40;short version of the Boston Naming Test&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> semantic verbal fluency&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> comprehension of commands&#41;&#44; motor apraxia &#40;EULA test<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#41;&#44; executive function &#40;WAIS similarities&#44; coin test from the Eurotest&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> semantic verbal fluency&#41;&#44; and visuospatial function &#40;copy and drawing&#41;&#44; in addition to a formal functional evaluation&#46; The researcher performing the assessment &#40;SLA&#41; was blinded to Mini-Cog&#44; CDT&#44; and Fototest results&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Mini-Cog</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Version used</span><p id="par0055" class="elsevierStylePara elsevierViewall">We used the Mini-Cog<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> version including the words &#8220;capit&#225;n&#44;&#8221; &#8220;jard&#237;n&#44;&#8221; and &#8220;retrato&#8221; &#40;captain&#44; garden&#44; picture&#41;&#44; the word combination showing the most homogeneous frequency of use in Spanish &#40;58&#46;67&#44; 62&#46;45&#44; and 38&#46;42 occurrences per million words&#44; respectively&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> and the clock time &#8220;10 past 11&#44;&#8221; the most frequently used clock time in our setting&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Administration</span><p id="par0060" class="elsevierStylePara elsevierViewall">Patients were given the following instructions&#58; &#8220;Please listen carefully&#46; I am going to say 3 words that I want you to repeat back to me&#59; try to remember them as I will ask you to repeat them again&#46;&#8221; If the person was unable to repeat all 3 words&#44; the instructions were repeated up to 3 times&#46; Patients were then given a blank sheet and a pencil&#44; and the following instructions were given&#58; &#8220;Next&#44; I want you to draw a large&#44; round clock for me&#46; First&#44; put all of the numbers in their places&#46; Then&#44; set the hands to 10 past 11&#46;&#8221; After the clock-drawing task was completed&#44; the patient was asked to recall the 3 words from the first task&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Scoring</span><p id="par0065" class="elsevierStylePara elsevierViewall">In the recall task&#44; one point was scored for each word that was correctly remembered&#46; The clock drawing task was scored the maximum score &#40;2 points&#41; if the drawing met all of the following conditions&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0070" class="elsevierStylePara elsevierViewall">The clock has all the numbers&#44; with no repetitions and no additional numbers&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0075" class="elsevierStylePara elsevierViewall">The numbers are placed in the correct order&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0080" class="elsevierStylePara elsevierViewall">The numbers are placed in the correct positions on the face of the clock&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0085" class="elsevierStylePara elsevierViewall">The hands are unequivocally set to the time asked&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">Any other situation&#44; including the patient refusing to draw the clock or being unable to do so due to physical limitations &#40;paresis&#44; tremor&#44; ataxia&#44; etc&#41;&#44; was scored 0 points&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Registry</span><p id="par0095" class="elsevierStylePara elsevierViewall">We recorded patients&#8217; scores&#44; the time taken to complete the test&#44; the total number of attempts to repeat the 3 words&#44; and the number of times the rater had to repeat the instructions for the clock drawing task&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Clock drawing test</span><p id="par0100" class="elsevierStylePara elsevierViewall">We used the scoring system of the Spanish-language version of the Seven-Minute Screen<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> to score the clock drawing task in the Mini-Cog&#59; this system scores one point for each of the following criteria&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1</span><p id="par0105" class="elsevierStylePara elsevierViewall">The clock has all numbers from 1 to 12 &#40;using either Arabic or Roman numerals&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2</span><p id="par0110" class="elsevierStylePara elsevierViewall">The numbers are placed in the correct ascending order &#40;even if not all 12 numbers have been placed&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3</span><p id="par0115" class="elsevierStylePara elsevierViewall">The numbers are in the correct positions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">4</span><p id="par0120" class="elsevierStylePara elsevierViewall">The clock has 2 hands &#40;circles or other marks are not valid&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">5</span><p id="par0125" class="elsevierStylePara elsevierViewall">The hour hand &#40;or any other mark&#41; is set to 11&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">6</span><p id="par0130" class="elsevierStylePara elsevierViewall">The minute hand &#40;or any other mark&#41; is set to 10&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">7</span><p id="par0135" class="elsevierStylePara elsevierViewall">The hour hand is shorter than the minute hand &#40;or the patient indicates so orally&#41;&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Diagnosis</span><p id="par0140" class="elsevierStylePara elsevierViewall">Regardless of the reason for consultation and the final aetiological diagnosis&#44; all patients were categorised by cognitive status&#44; as follows&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Normal cognitive function &#40;NCF&#41;&#58; no subjective cognitive complaints and age-&#44; sex-&#44; and education-adjusted Fototest scores above the 10th percentile&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Subjective cognitive complaints &#40;SCC&#41;&#58; presence of subjective cognitive complaints&#44; with normal results in the formal cognitive assessment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Cognitive impairment without associated functional limitations &#40;CIw&#47;o&#41;&#58; presence of alterations in at least one cognitive domain according to the formal cognitive assessment&#44; with no significant impact on functional status&#59; these individuals meet the National Institute of Aging&#8211;Alzheimer&#8217;s Association criteria for mild cognitive impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Cognitive impairment with associated functional limitations &#40;CIw&#41;&#58; presence of alterations in at least one cognitive domain according to the formal cognitive assessment&#44; with significant impact on functional status&#59; these individuals meet the National Institute of Aging&#8211;Alzheimer&#8217;s Association criteria for dementia&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> In line with the recommendations of other authors&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> we avoid using the term &#8220;dementia&#8221; due to its negative connotations and the associated stigma&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Statistical analysis</span><p id="par0165" class="elsevierStylePara elsevierViewall">We conducted a descriptive study of sociodemographic variables and results&#44; stratified by diagnosis&#59; comparisons were performed using ANOVA and the chi-square test&#44; depending on whether variables were continuous or categorical&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The diagnostic usefulness of the tests was evaluated with the area under the ROC curve in patients with &#40;CIw&#47;o&#8239;&#43;&#8239;CIw&#41; vs without cognitive impairment &#40;NCF&#8239;&#43;&#8239;SCC&#41;&#46; We calculated the sensitivity&#44; specificity&#44; and positive and negative likelihood ratios for different cut-off points&#46; We used the Hanley and McNeil method for comparing ROC curves from the same sample<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> and the DeLong method for comparing ROC curves from independent samples&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> All parameters were calculated with 95&#37; confidence intervals and two-way comparisons with an alpha error of 0&#46;05&#46; Statistical analysis was performed with MedCalc&#44; version 18&#46;9&#46;1&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Formal considerations</span><p id="par0175" class="elsevierStylePara elsevierViewall">The study design and manuscript preparation follow the STARD recommendations for studies evaluating diagnostic tests&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><p id="par0180" class="elsevierStylePara elsevierViewall">We included a total of 581 individuals&#44; 266 of whom &#40;45&#46;8&#37;&#41; did not have cognitive impairment&#59; 94 of these &#40;16&#46;2&#37;&#41; had SCC&#46; The remaining 315 &#40;54&#46;2&#37;&#41; had cognitive impairment&#58; 127 &#40;21&#46;9&#37;&#41; had no functional limitations and 188 &#40;32&#46;1&#37;&#41; presented functional limitations&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the sociodemographic characteristics and cognitive assessment results of our sample&#46; Participants had a mean &#40;SD&#41; age of 63&#46;8 &#40;14&#46;4&#41; years &#40;range&#44; 15&#8211;92&#41; and 55&#46;1&#37; were women&#46; No differences in sex distribution were observed between groups &#40;&#967;<span class="elsevierStyleSup">2</span>&#8239;&#61;&#8239;3&#46;94&#59; not significant&#41; but we did observe differences in age&#44; which increased with poorer cognitive status &#40;F&#8239;&#61;&#8239;121&#46;9&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&#41;&#44; and education level&#44; which was lower in individuals with poorer cognitive status &#40;&#967;<span class="elsevierStyleSup">2</span>&#8239;&#61;&#8239;53&#46;68&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&#41;&#46; We also observed an inverse correlation between the percentage of illiterate individuals and cognitive status &#40;&#967;<span class="elsevierStyleSup">2</span>&#8239;&#61;&#8239;61&#46;17&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">Cognitive test results showed a significant negative correlation with cognitive status &#40;F&#8239;&#61;&#8239;210&#46;7 for the Mini-Cog and F&#8239;&#61;&#8239;126&#46;9 for the CDT&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;0001 for both&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">Individuals with cognitive impairment completed the Mini-Cog in a mean of 119&#46;5 &#40;36&#46;3&#41; seconds &#40;range&#44; 55-266&#41;&#44; nearly half a minute longer than it took individuals without cognitive impairment to complete the test &#40;93&#46;2 &#91;30&#46;4&#93; seconds &#91;range&#44; 49-251&#93;&#41;&#59; the difference is highly significant &#40;F&#8239;&#61;&#8239;34&#46;2&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;0001&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The diagnostic usefulness &#40;area under the ROC curve&#8239;&#177;&#8239;standard error&#41; of the Mini-Cog was significantly higher than that of the CDT &#40;0&#46;88&#8239;&#177;&#8239;0&#46;01 vs 0&#46;84&#8239;&#177;&#8239;0&#46;01&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;01&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The diagnostic usefulness of the Mini-Cog and the CDT was highly influenced by level of education&#59; performance was clearly poorer among individuals without primary studies &#40;0&#46;74&#8239;&#177;&#8239;0&#46;05 and 0&#46;75&#8239;&#177;&#8239;0&#46;05&#44; respectively&#41; than among individuals with at least primary studies &#40;0&#46;90&#8239;&#177;&#8239;0&#46;01 and 0&#46;84&#8239;&#177;&#8239;0&#46;02&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">With the optimal cut-off point &#40;2&#47;3&#41;&#44; the Mini-Cog has greater sensitivity &#40;0&#46;90&#41; than specificity &#40;0&#46;71&#41;&#44; correctly classifying 81&#46;4&#37; of the sample &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#59; the CDT &#40;cut-off point of 5&#47;6&#44; the score with the best diagnostic performance&#41;&#44; in contrast&#44; has greater specificity &#40;0&#46;80&#41; than sensitivity &#40;0&#46;77&#41;&#44; correctly classifying only 78&#46;5&#37; of individuals &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0205" class="elsevierStylePara elsevierViewall">Our study included a large&#44; heterogeneous sample of individuals attended at a neurology clinic&#44; with a high prevalence of cognitive problems&#46; In our sample&#44; the Mini-Cog showed clearly greater diagnostic usefulness than the CDT&#59; for both tests&#44; the diagnostic usefulness is highly influenced by the patient education level&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The CDT presents limited diagnostic usefulness for cognitive impairment &#40;area under the ROC curve&#58; 0&#46;84&#8239;&#177;&#8239;0&#46;02&#41;&#59; this is consistent with the results reported in previous studies&#44; regardless of the correction method used&#44; the setting&#44; or the geographical location of the sample&#46; Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> and Duro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> evaluated the diagnostic usefulness of the CDT for MCI using different correction methods&#59; Ehreke et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> conducted a systematic review and concluded that the CDT is not suitable for cognitive impairment screening&#46; A previous study conducted by our research group&#44; including patients from primary care consultations and using the same grading system&#44; shows identical results &#40;0&#46;84&#8239;&#177;&#8239;0&#46;02&#41;&#59; however&#44; the study conducted by Cacho et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> including patients attended at a neurology department and using a 10-point grading system&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> reports an even lower diagnostic usefulness for cognitive impairment &#40;0&#46;78&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The limited usefulness of the CDT may be due to the fact that the test does not specifically evaluate memory&#44; the cognitive domain most frequently affected in patients with cognitive impairment&#59; this would explain the superiority of the Mini-Cog&#44; whose main difference with respect to the CDT is the inclusion of a free recall task&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The diagnostic usefulness of the Mini-Cog in our setting is acceptable &#40;area under the ROC curve&#58; 0&#46;88&#8239;&#177;&#8239;0&#46;02&#41;&#44; similarly to the results of a study including a multiethnic sample with high prevalence of cognitive impairment &#40;62&#46;3&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> and was clearly superior to the values obtained in 2 studies conducted in the primary care setting &#40;with areas under the ROC curve of 0&#46;66 and 0&#46;77&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;25</span></a> The main difference between this study and our previous study<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> is that in the previous study&#44; Mini-Cog scores were calculated retrospectively by combining the results of the CDT and the recall task of the MMSE&#44; using a different word combination &#40;bicycle&#44; horse&#44; apple&#41; and clock time &#40;20 to 8&#41; in part of the sample&#59; this may have led to an underestimation of the test&#8217;s usefulness&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Both the Mini-Cog and the CDT also present other limitations&#46; Firstly&#44; they have a narrow score range &#40;0-5 for the Mini-Cog and 0-7 for the CDT&#41;&#44; which may favour ceiling or floor effects&#44; as observed in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#46; Furthermore&#44; and more importantly&#44; both tests require minimum graphomotor skills&#44; and are therefore unsuitable for illiterate individuals or those with a low education level&#59; this may explain why the diagnostic usefulness of both tools is limited in individuals who had not completed primary education&#46; These tools should therefore not be used in this population group&#46; This is consistent with the results of other studies evaluating the performance of the Mini-Cog in samples of individuals with low education levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;49</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The main strength of these tools is their brevity&#46; In our study&#44; the maximum completion time was 266 seconds&#44; and 95&#37; of participants completed the Mini-Cog in less than 3&#160;minutes &#40;95th percentile&#58; 178&#46;2 seconds&#41;&#59; in fact&#44; mean &#40;SD&#41; completion time for patients with cognitive impairment was less than 2&#160;minutes &#40;119&#46;4 &#91;36&#46;3&#93;&#41;&#46; These results are very similar to those reported in a study including individuals attended at a primary care consultation&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> who completed the Mini-Cog in a mean time of 118 &#40;45&#41; seconds&#44; with no participant requiring longer than 5&#160;minutes&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">One of the strengths of this study is the large size and naturalistic character of the sample&#44; since we systematically included all individuals attended at a neurology clinic&#44; regardless of the reason for consultation&#46; This recruitment method limits the risk of selection bias and increases the external validity of our results&#46; Its weaknesses include the fact that controls did not undergo a formal cognitive assessment&#59; presence of cognitive impairment was determined based on the clinical history and Fototest results&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Though valid&#44; this tool cannot rule out the presence of false negatives&#44; making it difficult to discriminate between patients with and without cognitive impairment&#46; The risk of false positives was not a concern since all participants underwent a formal cognitive assessment&#46; Finally&#44; the functions of the neurology clinic where the study was conducted fall between those of a unit specialising in cognitive impairment and those of a general neurology consultation&#44; which limits the applicability of our results to other settings&#44; such as primary care or the general population&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In conclusion&#44; the Mini-Cog has greater diagnostic usefulness than the CDT in screening for cognitive impairment in neurology consultations&#44; but is unsuitable for the assessment of individuals with low levels of education&#46; The test&#8217;s simplicity and speed of use make it particularly useful for application in combination with other brief cognitive tests&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0245" class="elsevierStylePara elsevierViewall">C&#46; Carnero Pardo created the Fototest and has received professional fees for academic and consulting activities for Nutricia&#44; Schwabe Farma Ib&#233;rica&#44; Biogen&#44; Piramal&#44; Janssen Cilag&#44; Pfizer&#44; Eisai&#44; Esteve&#44; Novartis&#44; Lundbeck&#44; and Grunenthal&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Under the terms of its Creative Commons licence&#44; Fototest may be used and distributed for non-commercial purposes provided that it is not modified and its authorship is explicitly acknowledged&#46;</p></span></span>"
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            0 => "Cognitive impairment"
            1 => "Detection"
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            0 => "Deterioro cognitivo"
            1 => "Detecci&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The Mini-Cog is a very brief&#44; widely used cognitive test that includes a memory task and a simplified assessment of the Clock Drawing Test &#40;CDT&#41;&#46; There is not a formal evaluation of the Mini-Cog test in Spanish&#46; This study aims to analyse the diagnostic usefulness of the Mini-Cog and CDT for detecting cognitive impairment &#40;CI&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">We performed a cross-sectional study&#44; systematically including all patients who consulted at our neurology clinic over a 6-month period&#46; We assessed diagnostic usefulness for detecting CI &#40;defined according to the National Institute on Aging-Alzheimer&#8217;s Association criteria for mild cognitive impairment and dementia&#41; according to the area under the receiver operating characteristic curve &#40;AUC&#41;&#46; Sensitivity&#44; specificity&#44; and positive and negative likelihood ratios were calculated for each cut-off point&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">The study included 581 individuals &#40;315 with CI&#41;&#59; 55&#46;1&#37; were women and 27&#46;7&#37; had not completed primary studies&#46; The Mini-Cog showed greater diagnostic usefulness than the CDT &#40;AUC&#8239;&#177;&#8239;sensitivity&#58; 0&#46;88&#8239;&#177;&#8239;0&#46;01 vs 0&#46;84&#8239;&#177;&#8239;0&#46;01&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;01&#41;&#46; Both instruments were less useful for screening in individuals with a low education level &#40;0&#46;74&#8239;&#177;&#8239;0&#46;05 vs 0&#46;75&#8239;&#177;&#8239;0&#46;05&#44; respectively&#41;&#46; A cut-off point of 2&#47;3 in the Mini-Cog achieved a sensitivity of 0&#46;90 &#40;95&#37; CI&#44; 0&#46;87-0&#46;93&#41; and a specificity of 0&#46;71 &#40;95&#37; CI&#44; 0&#46;65-0&#46;76&#41;&#59; a cut-off point of 5&#47;6 in the CDT achieved a sensitivity of 0&#46;77 &#40;95&#37; CI&#44; 0&#46;72-0&#46;81&#41; and a specificity of 0&#46;80 &#40;95&#37; CI&#44; 0&#46;75-0&#46;85&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">In our neurology clinic&#44; the Mini-Cog showed acceptable diagnostic usefulness for detecting CI&#44; greater than that of the CDT&#59; neither test is an appropriate instrument for individuals with a low level of education&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y Objetivos</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">El Mini-Cog es un test cognitivo muy breve de uso extendido que incluye una tarea de memoria y una evaluaci&#243;n simplificada del Test del Reloj &#40;TdR&#41;&#46; No existe una evaluaci&#243;n formal del Mini-Cog en espa&#241;ol&#59; nuestro objetivo es analizar la utilidad diagn&#243;stica &#40;UD&#41; del Mini-Cog y del TdR para deterioro cognitivo &#40;DC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal en el que se han incluido de forma sistem&#225;tica todos los sujetos atendidos durante un semestre en una consulta de Neurolog&#237;a&#46; La UD se ha evaluado para DC &#40;incluye sujetos con criterios NIA-AA de <span class="elsevierStyleItalic">mild cognitive impairment</span> o demencia&#41; por medio del &#225;rea bajo la curva ROC &#40;aROC&#41;&#46; Se han calculado los par&#225;metros de sensibilidad &#40;S&#41;&#44; especificidad &#40;E&#41; y cocientes de probabilidad positivo y negativo &#40;CP&#43;&#44; CP-&#41; para los distintos puntos de corte&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Se han incluido 581 sujetos &#40;315 DC&#41;&#44; 55&#46;1&#37; mujeres y 27&#46;7&#37; con bajo nivel educativo &#40;&#60; estudios primarios&#41;&#46; La UD del Mini-Cog es superior a la del TdR &#40;0&#46;88&#8239;&#177;&#8239;0&#46;01 &#40;aROC&#8239;&#177;&#8239;ee&#41; vs 0&#46;84&#8239;&#177;&#8239;0&#46;01&#44; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;01&#41;&#59; para ambos instrumentos&#44; la UD disminuye notablemente en sujetos con bajo nivel educativo &#40;0&#46;74&#8239;&#177;&#8239;0&#46;05 y 0&#46;75&#8239;&#177;&#8239;0&#46;05 respectivamente&#41;&#46; El punto de corte 2&#47;3 del Mini-Cog tiene una S 0&#46;90 &#40;0&#46;87&#8722;0&#46;93&#41; y una E 0&#46;71 &#40;0&#46;65&#8722;0&#46;76&#41; y el 5&#47;6 del TdR una S 0&#46;77 &#40;0&#46;72&#8722;0&#46;81&#41; y E 0&#46;80 &#40;0&#46;75&#8722;0&#46;85&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">En consulta de Neurolog&#237;a&#44; el Mini-Cog tiene una UD para DC aceptable&#44; superior a la del TdR&#59; ninguno de ellos es un instrumento adecuado para ser utilizado en sujetos con bajo nivel educativo&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Carnero-Pardo C&#44; Rego-Garc&#237;a I&#44; Barrios-L&#243;pez JM&#44; Blanco-Madera S&#44; Calle-Calle R&#44; L&#243;pez-Alcalde S&#44; et al&#46; Evaluaci&#243;n de la utilidad diagn&#243;stica y validez discriminativa del Test del Reloj y del Mini-Cog en la detecci&#243;n del deterioro cognitivo&#46; Neurolog&#237;a&#46; 2022&#59;37&#58;13&#8211;20&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">An interim analysis of this study was presented orally at the 70th Annual Meeting of the Spanish Society of Neurology&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Violin plot showing Mini-Cog scores&#44; stratified by cognitive status&#46; The white dots represent median scores&#44; the ends of the black bars represent the 25th and 75th percentiles&#44; and the length of the line is 1&#46;5 times the interquartile range&#59; the violin shape represents the density distribution of the data&#44; extending to the extreme high and low values&#46; CIw&#58; cognitive impairment with associated functional limitations&#59; CIw&#47;o&#58; cognitive impairment without associated functional limitations&#59; NCF&#58; normal cognitive function&#59; SCC&#58; subjective cognitive complaints&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Violin plot showing clock drawing test scores&#44; stratified by cognitive status&#46; The white dots represent median scores&#44; the ends of the black bars represent the 25th and 75th percentiles&#44; and the length of the line is 1&#46;5 times the interquartile range&#59; the violin shape represents the density distribution of the data&#44; extending to the extreme high and low values&#46; CIw&#58; cognitive impairment with associated functional limitations&#59; CIw&#47;o&#58; cognitive impairment without associated functional limitations&#59; NCF&#58; normal cognitive function&#59; SCC&#58; subjective cognitive complaints&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">ROC curves for the Mini-Cog and the clock drawing test &#40;CDT&#41; for cognitive impairment&#46; Data represent the area under the ROC curve&#8239;&#177;&#8239;standard error&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CI&#58; cognitive impairment&#59; CIw&#58; cognitive impairment with associated functional limitations&#59; CIw&#47;o&#58; cognitive impairment without associated functional limitations&#59; NCF&#58; normal cognitive function&#59; SCC&#58; subjective cognitive complaints&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Data are expressed either as absolute frequency &#40;&#37;&#41; or mean &#40;standard deviation&#41;&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">119&#46;9 &#40;36&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">107&#46;6 &#40;36&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&#46;2 &#40;30&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">119&#46;5 &#40;36&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#8805; Primary education &#40;n&#8239;&#61;&#8239;412&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Mini-Cog&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">0&#46;84&#8239;&#177;&#8239;0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;75&#8239;&#177;&#8239;0&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84&#8239;&#177;&#8239;0&#46;02&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;85 &#40;0&#46;80-0&#46;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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ISSN: 21735808
Original language: English
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