不同画钟试验识别急性期卒中后非痴呆型认知障碍的价值

doi:10.3969/j.issn.1004-583X.2023.02.008

摘要/Abstract

摘要：

目的探讨3种画钟试验(clock drawing test, CDT)及错误类型识别急性卒中后非痴呆型认知障碍(post-stroke cognitive impairment no dementia, PSCIND)的价值。方法选取2019年10月至2021年4月于河北省人民医院神经内科就诊的急性期PSCIND患者104例为PSCIND组,同时期河北省人民医院体检中心健康体检者95例为对照组。所有研究对象均进行认知功能评估,包括CDT(Babins法、Cohen法和3分法)和简易智能状态精神量表(Mini-Mental State Examination, MMSE),并进行CDT错误类型分析。通过受试者工作特征(Receiver Operating Characteristic, ROC) 曲线比较不同CDT评分方法、MMSE评分和不同CDT评分方法联合MMSE评分后的诊断价值。结果 CDT评分Babins、Cohen法和MMSE评分是PSCIND的独立危险因素。CDT评分Babins、Cohen法及MMSE评分诊断PSCIND的敏感度分别为87.5%、58.7%、76.9%,特异度分别为55.8%、81.1%、61.1%。CDT评分Babins、Cohen法联合MMSE评分后敏感度分别为57.5%和70.2%,特异度分别为85.3%和75.8%。错误类型分析发现,两组常见错误类型主要是概念缺失(Ⅳ类错误)、空间计划错误(Ⅴ类错误)和绘图困难(Ⅱ类错误)。与对照组相比,PSCIND组Ⅱ类错误、刺激-限制反应(Ⅲ类错误)、Ⅳ类错误和重复(Ⅵ类错误)占比较大(均P<0.05)。结论单独应用CDT评分并不能很好地识别PSCIND,但联合MMSE评分后,CDT评分Cohen法可很好识别PSCIND, 敏感度和特异度均较高。CDT错误类型能很好地区别PSCIND和健康对照者,可作为PSCIND初步筛查工具。

关键词: 认知障碍, 卒中, 画钟试验, 敏感性与特异性

Abstract:

Objective To explore the value of three clock drawing tests (CDT) scoring systems and error types in identifying acute post-stroke cognitive impairment no dementia (PSCIND). Methods From October 2019 to April 2021, 114 patients with acute PSCIND treated in the Department of Neurology, Hebei General Hospital were as the PSCIND group, meantime, 95 healthy examination people in the Department of Physical Examination of our hospital were as the control group. The cognitive functions of these patients were assessed, including CDT scoring systems (Cahn, Babins, and three-point) and Mini Mental State Examination (MMSE),and an analysis of CDT error type was performed between the two groups. The receiver operating characteristic (ROC) curve was conducted to identify the diagnostic value of CDT, MMSE, and the two combination for PSCIND. Results Babins, Cohen of CDT scoring systems and MMSE score were independent risk factors for PSCIND. The sensitivity and the specificity of Babins, Cohen and MMSE in the diagnosis of PSCIND was (87.5% vs 58.7% vs 76.9%) and (55.8% vs 81.1% vs 61.1%), respectively. The sensitivity and specificity of Babins and Cohen combined with MMSE were 57.5% and 70.2%, and 85.3% and 75.8% respectively. The analysis of error types found that the two groups of common error types were mainly concept loss (type Ⅳ error), space plan error (type Ⅴ error) and drawing difficulty (type Ⅱ error). Compared with the control group, PSCIND group accounted for more type Ⅱ errors, stimulus-limiting response (type Ⅲ errors), type Ⅳ errors and repetition (type Ⅵ errors) (all P<0.05). Conclusion The CDT score applied alone fails to identify PSCIND well, while Cohen method of CDT score is eligible to identify PSCIND well with high sensitivity and specificity after being combined with MMSE score. CDT error types are eligible to well distinguish PSCIND and control persons and be used as a preliminary screening tool for PSCIND.

Key words: cognition disorder, stroke, clock drawing test, sensitivity and specificity

中图分类号:

R741

贾阳娟, 韩凝, 郭慧, 李灿灿, 李建国. 不同画钟试验识别急性期卒中后非痴呆型认知障碍的价值[J]. 临床荟萃, 2023, 38(2): 143-148.

Jia Yangjuan, Han Ning, Guo Hui, Li Cancan, Li Jianguo. Value of different clock drawing tests in identifying acute post-stroke cognitive impairment no dementia[J]. Clinical Focus, 2023, 38(2): 143-148.

导出引用管理器 EndNote|Ris|BibTeX

链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2023.02.008

https://huicui.hebmu.edu.cn/CN/Y2023/V38/I2/143

图/表 7

表1 两组临床资料比较

Tab.1 Comparison of clinical data between the two groups

表2 PSCIND的相关危险因素分析

Tab.2 Analysis of relevant risk factors of PSCIND

因素	回归系数	标准误	Wald χ²值	$P$ 值	$O R$ 值	95% $C I$
因素	回归系数	标准误	Wald χ²值	$P$ 值	$O R$ 值	下限	上限
Babins法	-0.261	0.055	22.406	0.000	0.770	0.691	0.858
Cohen法	-0.315	0.067	22.231	0.000	0.730	0.640	0.832
3分法	-0.420	0.215	3.817	0.051	0.657	0.431	1.001
MMSE评分	-0.405	0.067	36.142	0.000	0.667	0.584	0.761

表2 PSCIND的相关危险因素分析

Tab.2 Analysis of relevant risk factors of PSCIND

因素	回归系数	标准误	Wald χ²值	$P$ 值	$O R$ 值	95% $C I$
因素	回归系数	标准误	Wald χ²值	$P$ 值	$O R$ 值	下限	上限
Babins法	-0.261	0.055	22.406	0.000	0.770	0.691	0.858
Cohen法	-0.315	0.067	22.231	0.000	0.730	0.640	0.832
3分法	-0.420	0.215	3.817	0.051	0.657	0.431	1.001
MMSE评分	-0.405	0.067	36.142	0.000	0.667	0.584	0.761

图1 MMSE和不同CDT评分方法预测PSCIND的ROC曲线

Fig.1 ROC curve of PSCIND predicted by MMSE and different CDT scoring methods

表3 不同CDT评分方法和MMSE对PSCIND的预测价值

Tab.3 The predictive value of different CDT scoring methods and MMSE on PSCIND

因素	AUC	标准误	$P$ 值	95% $C I$		敏感度	特异度	约登指数	界值
因素	AUC	标准误	$P$ 值	下限	上限	敏感度	特异度	约登指数	界值
CDT(Babins法)	0.759	0.035	0.000	0.691	0.826	87.5	55.8	0.433	16.5
CDT(Cohen法)	0.726	0.036	0.000	0.655	0.796	58.7	81.1	0.398	15.5
MMSE评分	0.752	0.034	0.000	0.686	0.818	76.9	61.1	0.385	26.5

表3 不同CDT评分方法和MMSE对PSCIND的预测价值

Tab.3 The predictive value of different CDT scoring methods and MMSE on PSCIND

因素	AUC	标准误	$P$ 值	95% $C I$		敏感度	特异度	约登指数	界值
因素	AUC	标准误	$P$ 值	下限	上限	敏感度	特异度	约登指数	界值
CDT(Babins法)	0.759	0.035	0.000	0.691	0.826	87.5	55.8	0.433	16.5
CDT(Cohen法)	0.726	0.036	0.000	0.655	0.796	58.7	81.1	0.398	15.5
MMSE评分	0.752	0.034	0.000	0.686	0.818	76.9	61.1	0.385	26.5

图2 不同CDT评分方法联合MMSE预测PSCIND的ROC曲线

Fig.2 ROC curve of PSCIND predicted by different CDT scoring methods combined with MMSE

表4 不同CDT评分方法联合MMSE对PSCIND的预测价值

Tab.4 Prediction value of different CDT scoring methods combined with MMSE on PSCIND

因素	AUC	标准误	$P$ 值	95% $C I$		敏感度	特异度	约登指数	界值
因素	AUC	标准误	$P$ 值	下限	上限	敏感度	特异度	约登指数	界值
MMSE+CDT(Babins法)	0.798	0.031	0.000	0.738	0.859	57.5	85.3	0.428	38.5
MMSE+CDT(Cohen法)	0.805	0.030	0.000	0.745	0.864	70.2	75.8	0.460	41.5

表4 不同CDT评分方法联合MMSE对PSCIND的预测价值

Tab.4 Prediction value of different CDT scoring methods combined with MMSE on PSCIND

因素	AUC	标准误	$P$ 值	95% $C I$		敏感度	特异度	约登指数	界值
因素	AUC	标准误	$P$ 值	下限	上限	敏感度	特异度	约登指数	界值
MMSE+CDT(Babins法)	0.798	0.031	0.000	0.738	0.859	57.5	85.3	0.428	38.5
MMSE+CDT(Cohen法)	0.805	0.030	0.000	0.745	0.864	70.2	75.8	0.460	41.5

表5 两组CDT错误类型比较[例(%)]

Tab.5 Comparison of CDT error types in the two groups[cases (%)]

组别	例数	Ⅰ类错误	Ⅱ类错误	Ⅲ类错误	Ⅳ类错误	Ⅴ类错误	Ⅵ类错误
对照组	95	10(10.5)	9(9.5)	8(8.4)	14(14.7)	12(12.6)	5(5.3)
PSCIND组	104	21(20.2)	36(34.6)	21(20.2)	31(29.8)	22(21.2)	16(15.4)
χ²值		3.527	17.934	5.526	6.444	2.545	148.24
$P$ 值		0.060	0.000	0.019	0.011	0.111	<0.01

表5 两组CDT错误类型比较[例(%)]

Tab.5 Comparison of CDT error types in the two groups[cases (%)]

组别	例数	Ⅰ类错误	Ⅱ类错误	Ⅲ类错误	Ⅳ类错误	Ⅴ类错误	Ⅵ类错误
对照组	95	10(10.5)	9(9.5)	8(8.4)	14(14.7)	12(12.6)	5(5.3)
PSCIND组	104	21(20.2)	36(34.6)	21(20.2)	31(29.8)	22(21.2)	16(15.4)
χ²值		3.527	17.934	5.526	6.444	2.545	148.24
$P$ 值		0.060	0.000	0.019	0.011	0.111	<0.01

参考文献 20

[1]	Morsund H, Ellekjaer H, Gramstad A, et al. The development of cognitive and emotional impairment after a minor stroke: A longitudinal study[J]. Acta Neurol Scand, 2019, 140(4):281-289. doi: 10.1111/ane.13143 pmid: 31265131
[2]	Duro D, Freitas S, Tábuas-Pereira M, et al. Discriminative capacity and construct validity of the Clock Drawing Test in mild cognitive impairment and Alzheimer's disease[J]. Clin Neuropsychol, 2019, 33(7):1159-1174. doi: 10.1080/13854046.2018.1532022 pmid: 30422076
[3]	Champod AS, Gubitz GJ, Phillips SJ, et al. Clock Drawing Test in acute stroke and its relationship with long-term functional and cognitive outcomes[J]. Clin Neuropsychol, 2019, 33(5):817-830. doi: 10.1080/13854046.2018.1494307 pmid: 29985104
[4]	Chan JYC, Bat BKK, Wong A, et al. Evaluation of digital drawing tests and paper-and-pencil drawing tests for the screening of mild cognitive impairment and dementia: A systematic review and meta-analysis of diagnostic studies[J]. Neuropsychol Rev, 2022, 32(3):566-576. doi: 10.1007/s11065-021-09523-2
[5]	Cova I, Mele F, Zerini F, et al. The Clock Drawing Test as a predictor of cognitive decline in non-demented stroke patients[J]. J Neurol, 2022, 269(1):342-349. doi: 10.1007/s00415-021-10637-z
[6]	Mele F, Cova I, Benzi F, et al. Predictivity of the clock drawing test in the acute phase of cerebrovascular diseases on cognitive decline at a 6-month neuropsychological evaluation[J]. Neurol Sci, 2022, 43(3):2073-2076. doi: 10.1007/s10072-021-05809-8 pmid: 35001189
[7]	Kim S, Jahng S, Yu KH, et al. Usefulness of the Clock Drawing Test as a cognitive screening instrument for mild cognitive impairment and mild dementia: An evaluation using three scoring systems[J]. Dement Neurocogn Disord, 2018, 17(3):100-109. doi: 10.12779/dnd.2018.17.3.100 pmid: 30906399
[8]	Carnero-Pardo C, Rego-García I, Barrios-López JM, et al. Assessment of the diagnostic accuracy and discriminative validity of the Clock Drawing and Mini-Cog tests in detecting cognitive impairment[J]. Neurologia (Engl Ed), 2022, 37(1):13-20.
[9]	中国医师协会神经内科分会认知障碍专业委员会, 《中国血管性认知障碍诊治指南》编写组. 2019年中国血管性认知障碍诊治指南[J]. 中华医学杂志, 2019, 99(35):2737-2744.
[10]	Babins L, Slater ME, Whitehead V, et al. Can an 18-point clock- drawing scoring system predict dementia in elderly individuals with mild cognitive impairment?[J]. J Clin Exp Neuropsychol, 2008, 30(2):173-186. doi: 10.1080/13803390701336411 URL
[11]	Cohen MJ, Ricci CA, Kibby MY, et al. Developmental progression of clock face drawing in children[J]. Child Neuropsychol, 2000, 6(1):64-76. pmid: 10980669
[12]	Lin KN, Wang PN, Chen C, et al. The three-item clock-drawing test: A simplified screening test for Alzheimer's disease[J]. Eur Neurol, 2003, 49(1):53-58. doi: 10.1159/000067026 URL
[13]	Parsey CM, Schmitter-Edgecombe M. Quantitative and qualitative analyses of the Clock Drawing Test in mild cognitive impairment and Alzheimer disease: Evaluation of a modified ccoring system[J]. J Geriatr Psychiatry Neurol, 2011, 24(2):108-118. doi: 10.1177/0891988711402349 URL
[14]	Charernboon T. Diagnostic accuracy of the Overlapping Infinity Loops, Wire Cube, and Clock Drawing Tests for cognitive impairment in mild cognitive impairment and dementia[J]. Int J Alzheimers Dis, 2017, 2017:5289239.
[15]	Kim S, Jahng S, Yu KH, et al. Usefulness of the Clock Drawing Test as a cognitive screening instrument for mild cognitive impairment and mild dementia: An evaluation using three scoring systems.[J]. Dement Neurocogn Disord, 2018, 17(3):100-109. doi: 10.12779/dnd.2018.17.3.100 pmid: 30906399
[16]	Costa S, St George RJ, McDonald JS, et al. Diagnostic accuracy of the Overlapping Infinity Loops, Wire Cube, and Clock Drawing Tests in subjective cognitive decline, mild cognitive impairment and dementia[J]. Geriatrics (Basel), 2022, 7(4):72.
[17]	Limpawattana P, Manjavong M. The Mini-Cog, Clock Drawing Test, and Three-Item Recall Test: Rapid cognitive screening tools with comparable performance in detecting mild NCD in older patients[J]. Geriatrics (Basel), 2021, 6(3):91.
[18]	Bouati N, Drevet S, Zerhouni N, et al. Cognitive screening tool for geriatrics: A retrospective observational study on the correlation of the scores in 30-Point Clock Face Test and MMSE[J]. Indian J Psychol Med, 2021, 43(4):306-311. doi: 10.1177/0253717620961335 pmid: 34385723
[19]	Umegaki H, Suzuki Y, Komiya H, et al. Association between gait speed and errors on the Clock Drawing Test in older adults with mild cognitive impairment[J]. Sci Rep, 2022, 12(1):9929. doi: 10.1038/s41598-022-14084-2 pmid: 35705650
[20]	Allone C, Lo Buono V, Corallo F, et al. Cognitive impairment in Parkinson's disease, Alzheimer's dementia, and vascular dementia: The role of the Clock-Drawing Test[J]. Psychogeriatrics, 2018, 18(2):123-131. doi: 10.1111/psyg.12294 pmid: 29417704