Clock Drawing Test Scoring · Shulman, Sunderland and Mini-Cog Methods
The clock drawing test is a brief cognitive screening task in which a person draws a clock face and sets the hands to a given time, used to help detect dementia in older adults. Several scoring systems exist; on Shulman's widely used 0 to 5 method, 4 or 5 is read as normal and 0 to 3 as abnormal.
For professional reference, research, and education only. Not for diagnosis or medical advice.
Clock Drawing Score Interpreter (Shulman 0-5 method)
Enter a total score to see its range.
Bands apply to the Shulman (2000) 0 to 5 method only, where higher scores mean a more accurate clock. Do not read Sunderland (10 to 1) or Mini-Cog (0 or 2) clock scores against this table.
Shulman clock score Interpretation 4+ Normal4 or 5 is classed as normal. Raters find it hard to tell 4 from 5, so the normal/abnormal split is more reliable than the exact score. 0–3 Abnormal0 to 3 is classed as abnormal and calls for a fuller cognitive evaluation. An abnormal clock does not diagnose dementia. Shulman (2000) scoring method; normal (4 or 5) versus abnormal (0 to 3) classification as used by Fuzikawa et al. (2003), with Shulman as co-author.
The clock drawing test asks a person to draw a clock face, put in the numbers and set the hands to a given time. It is quick, needs only paper and a pencil, and draws on several cognitive skills at once [1] [5]. There is no single version: more than fifteen scoring systems have been published, and no consensus on which is best [5].
What does the clock drawing test measure?
Drawing a clock calls on comprehension of the instructions, planning, visuospatial and constructional skill, numerical knowledge, memory and executive function [1] [5]. It was first used to detect constructional difficulties after brain lesions; in 1986 Shulman and colleagues linked it to cognitive screening in older adults [5]. Shulman's 2000 review concluded that it meets defined criteria for a cognitive screening test and complements the MMSE and informant reports [1].
A clock drawing is also built into other screens: the Mini-Cog pairs it with three-word recall, and the MoCA includes one among its executive tasks.
Terms of use
The clock drawing task is not a single form issued by one copyright holder. Each scoring system is set out in the journal article that describes it, cited on this page. The clock component of the Mini-Cog is part of the Mini-Cog, which has its own terms; see the Mini-Cog page.
How do you give the clock drawing test?
The instructions differ between systems, so follow the instructions for the scoring system you plan to use [1] [5]. The common elements are:
- Materials. A blank sheet, or a sheet with a circle already drawn; some systems ask the person to draw the circle as well.
- Instruction. Ask the person to draw a clock, put in all the numbers and set the hands to a specified time. Sunderland's method uses 2:45 [2]; the Mini-Cog uses ten past eleven [6].
- Who gives it. Any trained member of the care team. In one comparison, naive raters scored clocks almost as well as trained raters [5].
How do you score and interpret the clock drawing test?
Choose one scoring system and use it consistently. The commonly used methods below run in different directions, so a score only has meaning within its own system:
| Method | Range | Direction | Interpretation |
|---|---|---|---|
| Shulman (2000) | 0-5 | Higher is better | 4-5 normal; 0-3 abnormal [3] |
| Sunderland et al. (1989) | 10-1 | 10 best, 1 worst | Rated as a severity measure; the original study reports group means (4.9 vs 8.7) rather than a cut-off [2] |
| Mini-Cog clock | 0 or 2 | 2 is normal | 2 for a normal clock, 0 for an abnormal one; part of the 0-5 Mini-Cog total [6] |
Shulman method. Clocks are scored from 0 to 5, with higher scores for a more accurate clock. In a population sample of older adults with very low formal education, classifying clocks as normal (4 or 5) or abnormal (0 to 3) gave excellent agreement, while raters found it hard to separate a 4 from a 5 [3]. The interpreter at the top of this page uses this method.
Sunderland method. Raters judge a clock set to 2:45 on a scale from 10 (best) to 1 (worst). In the original study, people with Alzheimer's disease averaged 4.9 and controls 8.7 [2].
Mini-Cog clock. A normal clock has all numbers 1 to 12, each once, in the correct order and direction, with two hands pointing to the 11 and the 2; hand length is not scored. Anything else scores 0 [6].
Other published systems, such as the Mendez, Watson and Wolf-Klein methods, are compared in the studies below [4] [5].
Psychometric properties
- Review of early studies. Shulman's 2000 review reported a mean sensitivity and specificity of 85% across published studies, correlations with the MMSE and other cognitive tests generally above 0.5, high inter-rater and test-retest reliability, and sensitivity to cognitive change [1].
- Head-to-head comparison. In 127 consecutive referrals to a geriatric clinic (mean age 78.2), the area under the curve for dementia was 0.79 for the Shulman method, 0.78 for Mendez, 0.71 for Sunderland and 0.65 for Watson. Inter-rater (0.81 to 0.93) and intra-rater (0.87 to 0.96) reliability were high for all five methods, but the authors judged accuracy modest at best [4].
- Reliability with low education. Using the Shulman method in 202 older adults with very low formal education, agreement for normal versus abnormal was kappa 0.99 within raters and 0.94 between raters; for the full 0 to 5 score it was 0.88 and 0.74 [3].
- Sunderland method. In 67 people with Alzheimer's disease and 83 controls, inter-rater reliability for clocks drawn by people with Alzheimer's disease was r = 0.86, and scores correlated with three global measures of dementia severity [2].
- Later reviews. A 2009 review, citing Shulman, reported correlations with the MMSE from 0.30 to 0.77 (mean 0.61) and low sensitivity for very mild dementia across scales [5].
Limitations
- Screening, not diagnosis. An abnormal clock calls for further evaluation; it does not diagnose dementia or show its cause [1].
- Weak for early change. Sensitivity is low in very mild dementia [5], and one comparison cautioned against using clock drawing alone to screen for dementia [4].
- No standard version. Instructions, set times and scoring differ between systems, and no consensus exists on the best scale [5]. Scores from different systems are not interchangeable.
- Narrow profile. Pair it with memory testing, as the Mini-Cog does, or use a fuller screen such as the MoCA, SLUMS or BIMS in nursing homes. Informant reports such as the IQCODE, staging scales such as FAST or the Global Deterioration Scale, and a depression screen such as the GDS answer different questions.
For individuals: This page is a clinical reference, not a diagnostic tool. If you have concerns about your own symptoms, bring this information to a qualified mental health professional.
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Assessments
FAQ
How do you score a clock drawing test?
It depends on the scoring system. On Shulman's 0 to 5 method, higher is better and 4 or 5 is read as normal. Sunderland's method rates the clock from 10 (best) to 1 (worst). The Mini-Cog scores the clock 2 for normal and 0 for abnormal. Use one system consistently so scores can be compared over time.
What is a normal clock drawing test score?
On Shulman's 0 to 5 method, a score of 4 or 5 is classed as normal and 0 to 3 as abnormal. In the Mini-Cog, a normal clock has all 12 numbers once each in the correct order and position, with hands pointing to the right numbers. Other systems use their own ranges, so a score only means something within its own system.
What does an abnormal clock drawing mean?
An abnormal clock suggests a problem with planning, visuospatial skill, comprehension or memory and calls for a fuller cognitive evaluation. It is not a diagnosis: accuracy for very mild dementia is low, and one study cautioned against using clock drawing alone to screen for dementia.
How accurate is the clock drawing test?
A 2000 review by Shulman reported a mean sensitivity and specificity of 85% across published studies. A later head-to-head study of five scoring methods in a geriatric clinic found more modest accuracy, with areas under the curve from 0.65 to 0.79; the Shulman and Mendez methods performed best.
References
- 1.Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry. 2000;15(6):548-61.
- 2.Sunderland T, Hill JL, Mellow AM, Lawlor BA, Gundersheimer J, Newhouse PA, Grafman JH. Clock drawing in Alzheimer's disease. A novel measure of dementia severity. J Am Geriatr Soc. 1989;37(8):725-9.
- 3.Fuzikawa C, Lima-Costa MF, Uchoa E, Barreto SM, Shulman K. A population based study on the intra and inter-rater reliability of the clock drawing test in Brazil: the Bambui Health and Ageing Study. Int J Geriatr Psychiatry. 2003;18(5):450-6.
- 4.Storey JE, Rowland JT, Basic D, Conforti DA. A comparison of five clock scoring methods using ROC (receiver operating characteristic) curve analysis. Int J Geriatr Psychiatry. 2001;16(4):394-9.
- 5.Aprahamian I, Martinelli JE, Neri AL, Yassuda MS. The Clock Drawing Test: A review of its accuracy in screening for dementia. Dement Neuropsychol. 2009;3(2):74-81.
- 6.Borson S. Scoring the Mini-Cog. mini-cog.com.
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