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

Neuropsychology Review

Chan, J. Y. C., Bat, B. K. K., et al. (2022).

Neuropsychology Review, 32, 566-576.

This systematic review with meta-analysis compares the diagnostic accuracy of digital drawing tests (e.g., clock drawing tests) to paper-and-pencil drawing tests for screening for mild cognitive impairment (MCI) and dementia in adults. Although speech-language pathologists do not diagnose dementia or MCI, findings from this review may be useful for identifying tools for detection of cognitive impairments in adult populations.

No funding received

Inception to March 31, 2020

Original diagnostic studies

90

Meta-analyses of studies investigating the diagnostic screening accuracy of digital clock drawing test (CDT) tools and paper-and-pencil CDT tools for screening for dementia in adults found that digital and paper-and-pencil CDT tools have comparable screening performance. "No significant difference was found between the diagnostic performance of digital CDT and brief scoring methods (P= 0.33) and detailed scoring methods (P=0.35) of paper-and-pencil CDT in the meta-regression model" (p. 570). Six studies found that digital CDT tools demonstrated pooled sensitivity of 0.83 (95% CI=0.72 to 0.90) and specificity of 0.87 (95% CI=0.79 to 0.92) for screening for dementia. Thirty studies found that paper-and-pencil CDT demonstrated sensitivity of 0.83 (95% CI = 0.77 to 0.87) and specificity of 0.80 (95% CI = 0.74 to 0.85) for the brief scoring method. For the detailed scoring method, 35 studies found that paper-and-pencil CDT demonstrated sensitivity of 0.80 (95% CI = 0.76 to 0.83) and specificity of 0.81 (95% CI = 0.75 to 0.86). The authors conclude that since "drawing tests in digital formats showed comparable [performance] to paper-in-pencil formats ... digital drawing tests can be a potential tool to use as an alternative for the screening of ... dementia" (p. 574).

Meta-analyses of studies investigating the diagnostic screening accuracy of digital clock drawing test (CDT) tools and paper-and-pencil CDT tools for screening for MCI found that digital CDT tools demonstrated better performance than paper-and-pencil CDT. "The diagnostic performance of digital CDT was significantly better than the brief scoring methods (P=0.02) and detailed scoring methods (P<0.001) of paper-and-pencil CDT" (p. 5705). Four studies found that digital CDT tools demonstrated pooled sensitivity of 0.86 (95% CI=0.75 to 0.92) and specificity of 0.92 (95% CI=0.69 to 0.98). Nine studies found that paper-and-pencil CDT demonstrated pooled sensitivity of 0.63 (95% CI=0.49 to 0.75) and specificity of 0.77 (95% CI=0.68 to 0.84) for the brief scoring method. For the detailed scoring method, 21 studies found that paper-and-pencil CDT demonstrated pooled sensitivity of 0.63 (95% CI=0.56 to 0.71) and specificity of 0.72 (95% CI=0.65 to 0.78). The authors conclude that since "drawing tests in digital formats showed comparable [performance] to paper-in-pencil formats ... digital drawing tests can be a potential tool to use as an alternative for the screening of MCI" (p. 374).

One study investigating the diagnostic screening accuracy of the digital Rey-Osterrieth complex figure (ROCF) tool reported sensitivity of 0.76 and specificity of 0.86 for screening for MCI in adults. Another study investigating the diagnostic screening accuracy of the paper-and-pencil ROCF reported sensitivity of 0.59 and specificity of 0.96 for screening for MCI. The authors conclude that since "drawing tests in digital formats showed comparable [performance] to paper-in-pencil formats ... digital drawing tests can be a potential tool to use as an alternative for the screening of MCI" (p. 574).

Meta-analyses of studies investigating the diagnostic accuracy of digital pentagon drawing test and paper-and-pencil pentagon drawing test for screening for dementia in adults found comparable performance. Two studies investigating the digital pentagon drawing test reported pooled sensitivity of 0.79 (95% CI = 0.74 to 0.85) and specificity of 0.74 (95% CI = 0.68 to 0.78). Four studies investigating the paper-and-pencil pentagon drawing test reported pooled sensitivity of 0.85 (95% CI = 0.70 to 0.94) and specificity of 0.73 (95% CI=0.52 to 0.87). The authors conclude that since "drawing tests in digital formats showed comparable [performance] to paper-in-pencil formats ... digital drawing tests can be a potential tool to use as an alternative for the screening of ... dementia" (p. 574).