DCR Test Comparable to Other Traditional Cognitive Screening Assessments, With Less Administration Time


A comparison between impaired scores on Digital Clock and Recall and impaired scores on Montreal Cognitive Assessment produced a 76% concordance.

Dustin B. Hammers, PhD, MS, associate professor of neurology at the Indiana University School of Medicine

Dustin B. Hammers, PhD, MS

In a comparative study, findings showed that cognitive screening in primary care settings was faster using the Digital Clock and Recall (DCR) than other traditional tests like the Montreal Cognitive Assessment (MoCA) and St. Louis University Mental Status (SLUMS). Performance on the DCR was concordant with the other previously established measures as well.1

Presented at the 2023 Alzheimer’s Association International Conference (AAIC), held June 16-20, in Amsterdam, Netherlands, the study comprised of 114 participants aged at least 65 years who scored in the Borderline Cognitive Impaired or Cognitive Impaired categories on the CDR and completed the MoCA. An additional 13 patients whose DCR performance was borderline or indicative of cognitive impairment completed all 3 assessments, which included SLUMS.

Led by Dustin B. Hammers, PhD, MS, associate professor of neurology at the Indiana University School of Medicine, results showed that borderline impairment on DCR corresponded to MoCA total scores and MoCA Memory Index Score (MIS) scores slightly below traditional cutoffs (23.65 [SD, 3.3] and 11.65 [SD, 3.2], respectively). Similarly, individuals considered Impaired, indicated by scores of 0-1, corresponded to MoCA total scores and MIS scores well-below cutoffs (21.20 [SD, 4.2] and 9.61 [SD, 3.9], respectively).

In the comparison analysis between DCR and SLUMS, all 13 patients had Impaired DCR scores and SLUMS scores. Impaired DCR scores of 0-3 and impaired MoCA total scores of less than 26 had a 76% concordance with each other, while the remaining 24% of patients with impaired DCR scores had normal MoCA total scores. When MoCA total scores were paired with low DCR Delayed Recall performance, concordance was increased to 81% (76 of 94).

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A receiver operating characteristic area under the curve analysis further revealed that the combination of DCR total score (0-5), DCTclock score (0-100), DCR Delayed Recall score (0-3), and age had the strongest ability to discriminate MoCA total score impairment (AUC = .90). Overall, the comparison between impaired DCR Scores (0-3) and impaired MoCA total score was strong, and even stronger in those with memory deficits on DCR Delayed Recall.

In comparison with other traditional paper-based measures, digital technologies like DCR and DCTclock require minimal training, are standardized and objective, and incorporate multilanguage support. In addition, digital strategies included automated scoring and interpretation, fast online results, results tracking, and offer greater or comparable sensitivity in early stages of cognitive impairment relative to traditional methods.2

In 2021, research on DCTclock using participants from the Harvard Aging Brain Study was published, with findings showing that the digital clock-drawing test was effective in identifying the early changes in AD pathology in cognitively normal individuals. The study included 300 participants, 264 of whom were cognitively normal (CN) and 36 with a diagnosis of mild cognitive impairment (MCI) or early AD dementia. Among CN participants with biomarkers, the DCTclock summary score and spatial reasoning subscores were associated with greater amyloid and tau burden and showed better discrimination (Cohen d = 0.76) between amyloid-ß-positive groups than the Preclinical Alzheimer Cognitive Composite (PACC) assessment.3

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1. Hammers DB, Fowler N, Brosch J, et al. Comparative performance of the Digital Clock and Recall (DCR) test, Montreal Cognitive Assessment (MoCA), and Saint Louis University Mental Status (SLUMS) among patients in primary care. Presented at: 2023 Alzheimer’s Association International Conference; June 16-20; Amsterdam, Netherlands. Abstract
2. Digital Cognitive Assessments: Advancing cognitive testing. Linus Health. https://linushealth.com/advancing-cognitive-testing. Accessed July 13, 2023.
3. Rentz DM, Papp KV, Mayblyum DV, et al. Association of Digital clock drawing with PET amyloid and tau pathology in normal older adults. Neurology. 2021;96(14). doi:10.1212/WNL.0000000000011697
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