Clock-drawing Test:Normative Data Of Three Quantitative Scoring Methods For Chinese-speaking Adults In Shijiazhuang City And Clinical Utility In Patients With Acute Ischemic Stroke

China has the largest population and the largest aging population in the world.More and more elderly people are suffering from the threat of cognitive dysfunction.The clock-drawing test(CDT)is a simple cognitive assessment tool,which has many advantages,such as easy operation,short time consuming,little influenced by environment and educational level,etc.,and is widely used in the screening of cognitive decline nowadays.However,there are few studies on CDT norms for Chinese-speaking adults,and the norms for different quantitative scoring methods are even rarer.Although the value of total CDT score in the differentiation of moderate to severe vascular cognitive impairment has been confirmed in previous studies,the differential value of CDT subscore in the Chinese population has not been fully studied.In this study,CDT was conducted on healthy adults in two communities of Shijiazhuang City to establish CDT standardized values for the three quantitative scoring methods.Furthermore,CDT was evaluated in patients with acute ischemic stroke who were admitted to the Department of Neurology of Hebei General Hospital to observe the differential validity of CDT total score and subscore in patients with different degrees of cognitive impairment after acute ischemic stroke and normal controls.Part Ⅰ Clock-drawing test: Normative data of three quantitative scoring methods for Chinese-speaking adults in Shijiazhuang CityObjective: Our study aimed to explore the demographic influencing factors of CDT and provide standardized values for the three quantitative CDT scoring methods that were tailored for Chinese-speaking adults in Shijiazhuang City.Methods: Healthy adults who participated in the “Early Detection and Management of Alzheimer’s Disease” community service program in Yuxi and Liuying communities of Shijiazhuang City,Hebei Province from June 2018 to October 2019 were selected as study subjects.Mini-mental state examination(MMSE)was used to evaluate the subjects’ overall cognition.Demographic data were registered for the subjects who met the inclusion and exclusion criteria,and a battery of neurological tests including CDT were performed.The CDT was scored using the method derived from the Montreal cognitive assessment(Mo CA),Rouleau’s,and Babins’ scoring systems.The influence of age,education,and sex on the performance in the CDT was analyzed,and the normative data was established according to the influencing factors.Results: A total of 418 healthy adults were enrolled,aged between 35 and84 years.The average age was 63.03±7.79 years old,male: female=1.5: 1,and the average education level was 9.32±3.14 years.In all three scoring systems,the CDT scores were significantly correlated with age and years of education but not with sex.Normative data stratified by age and years of education were established.Conclusions: Age and education level were the key factors that affected the CDT scores.We provided CDT normative data using three quantitative scoring methods for Chinese-speaking adults in Shijiazhuang City.Part Ⅱ Clinical utility of CDT in patients with acute ischemic strokeObjective: To investigate the differential validity of CDT total score and subscore in patients with different degrees of cognitive impairment after acute ischemic stroke and normal controls.Methods: Patients with acute ischemic stroke who were hospitalized in the Department of Neurology of Hebei General Hospital from April 2014 to December 2018 were selected as the subjects.All patients in stable condition three weeks within the stroke onset were tested for MMSE and CDT.They were divided into three groups according to the MMSE scores stratified by education level: no cognitive impairment after stroke(No CI),minor cognitive impairment after stroke(Minor CI),and major cognitive impairment after stroke(Major CI).The normal control(NC)group was selected from the subjects in the norms research that were homogenous in age and education level to stroke patients to analyze the discriminant validity of the total score and subscore of the three CDT scoring methods for patients with ischemic stroke and normal controls.Results: A total of 336 patients with acute ischemic stroke were included.Among them,there were 105 patients in No CI group,180 in Minor CI group,51 in Major CI group,and 400 normal controls in NC group.No significant differences existed in age and education level among the four groups.CDT total scores and subscores showed significant differences between stroke patients and healthy individuals.Conclusions: CDT total scores and subscores provided good discriminant validity for patients with different degrees of cognitive impairment after acute ischemic stroke,thus providing certain help for the early screening of cognitive impairment after stroke and judging the severity of cognitive impairment.