Evaluation of cognitive dysfunction by the clock drawing test in multiple sclerosis and clinically isolated syndrome patients: Correlation with other neuropsychological tests

Selma Tekin; Levent S. Bir; Cağatay Oncel; Zeynep Unluturk; Emel Aydın

doi:10.17712/nsj.2022.4.20220019

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Figure 1
- The samples of clock drawing tests of patients, A) A 46-year-old female who was diagnosed secondary progressive multiple sclerosis. B) A 53-year-old male who was diagnosed primer progressive multiple sclerosis

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Table 1

- Demographic and clinical findings of population.

Characteristics	Patients (n=152)	Controls (n=98)	P-value
Characteristics	Mean±SD n (%)		P-value
Age, y	39.06±10,91	41.18±13.75	0.199
Gender
Female (%)	108 (71.1)	68 (69.4)	0.778
Male (%)	44 (28.9)	30 (30.6)	0.778
Education levels
Low (<8 years) Middle (9-12 years) High (>12 years)	74 (48.7) 31 (20.4) 47 (30.9)	48 (48.9) 19(19.3) 31(31.6)	0.221
Mean relaps number	3.68±2.67
Mean EDSS score	2.13±1.69
Mean disease duration, years	10.42±6.47
Clinical form
CIS	10 (6.6)
RRMS	119 (78.63)
SPMS	23 (15.1)
Symptom onset
Sensorial	47(30.9)
Motor	41(27)
Optic neuritis	35(23)
Brainstem	22(14.5)
Others	7 (4.6)
Treatment
Interferonβ-1a	61 (40.1)
Glatiramer Acetate	43(28.2)
Teriflunomide Dymetyl fumarate Fingolimode Ocrelizumab None	8(5.2) 5(3.2) 8(5.2) 20(13.1) 7(4.6)
Cognitive symptoms
Yes No	96(63.2) 56(36.8)

EDSS - Expanded Disability Status Scale, CIS - Clinically Isolated Syndrome, RRMS - Relapsing Remitting Multiple Sclerosis, SPMS - Secondary Progressive Multiple Sclerosis

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Table 2

- The comparison of the clock drawing test scores.

Subjects	CDT-4			CDT-10
	Mean±SD	Med (min - max)	P-value	Mean±SD	Med (min - max)	P-value
Patients n=152	3.01±1.11	3 (0- 4)	0.003	7.57±3.2	9 (0-10)	0.002
Controls n=98	3.42±0.92	4 (0-4)	0.003	8.64±2.57	10 (0-10)	0.002
CIS+RRMS n=129	3.16±1.02	4 (1-4)	<0.0001	7.99±2.9	9 (0-10)	<0.0001
SPMS n=23	2.09±1.12	2 (0-4)	<0.0001	4.91±3.62	5 (0-10)	<0.0001
Early stage of MS (<3 years) n=19 Controls n=98	3.57±0.69 3.41±0.91	4 (2-4) 4 (0-4)	0.603	9.10±1.62 8.64±2.56	10 (4-10) 10 (0-10)	0.709

CDT-4 - Clock Drawing Test according to 4 point, CDT-10 - Clock Drawing Test according to 10 point, CIS - Clinically Isolated Syndrome, RRMS - Relapsing Remitting Multiple Sclerosis, SPMS - Secondary Progressive Multiple Sclerosis, MS - Multiple Sclerosis, n - The number of subjects, Med - Median

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Table 3

- The significant correlation between CDT and all cognitive domains.

Cognitive domains	CDT (n=152)
	P-value	r		P-value	r
Visual Learning Tests	^*<0.0001	0.643	Verbal Fluency Tests	^*<0.0001	0.442
Visual Memory Tests	^*<0.0001	0.625	MMSE	^*<0.0001	0.470
Verbal learning Tests	^*<0.0001	0.400	SDMT	^*<0.0001	0.450
Verbal Memory Tests	^*<0.0001	0.360	Stroop Tests	^*<0.0001	-0.485
			Beck Depresssion Inventory	^*<0.0001	-0.280

CDT - Clock Drawing Test, MMSE - Minimental Status Examination, SDMT - Symbol Digit Modalities Test, n - The number of subjects both performed CDT and other neuropsychological tests,

↵* Significant at p-value<0.05

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Table 4

- The relation between CDT and onset symptom of disease.

CDT	Optic neuritis	Sensory symptoms	Motor symptoms	Brainstem symptoms	Others	P-value
CDT- 4	3.23±1	3.43±0.9	2.59±1.09	2.45±1.26	3.43 ±1.13	<0.0001^*
CDT- 4	4 (1 - 4)	4 (1 - 4)	3 (1 - 4) γ	2,5 (0 - 4) γ	4 (1 - 4)	<0.0001^*
CDT-10	8.11±2.87	8.64±2.54	6.44±3.16	6.27±3.94	8.29±3.73	<0.0001^*
CDT-10	10 (0 - 10)	10 (0 - 10)	7 (0 - 10) γ	8 (0 - 10) γ	10 (0 - 10)	<0.0001^*

γ - Difference according to sensory symptoms, Descriptive statistics were shown mean±standard deviation, median (min – max values), CDT - Clock Drawing Test,