| No (n=956) | Yes (n=64) | values | Age (years), mean (SD) | 72 (7.9) | 71 (7.8) | 76 (8.2) | |
Female, n (%) | 585 (57) | 551 (58) | 34 (53) | .78 |
| .26 |
| High school or less | 246 (24) | 224 (23) | 22 (34) |
|
| Some college | 316 (31) | 295 (31) | 21 (33) |
|
| College or higher | 458 (45) | 437 (46) | 21 (33) |
|
Mild cognitive impairment, n (%) | 43 (4) | 36 (4) | 7 (11) | |
White matter hyperintensities, mean (SD) | 0.0 (1.0) | –0.04 (1.0) | 0.49 (1.0) | |
|
| Command clock, median (IQR) | 0 (0-3) | 0 (0-2) | 0 (0-3) | .36 |
| Copy clock, median (IQR) | 0 (0-2) | 0 (0-1) | 0 (0-2) | .30 |
, mean (SD) |
| Overall DCT score | 76 (20) | 76 (20) | 68 (23) | |
|
| |
|
| Drawing efficiency | 62 (10) | 62 (10) | 60 (12) | .41 |
|
| Simple motor | 63 (8.1) | 63 (8.0) | 63 (9.0) | .89 |
|
| Information processing | 60 (9.9) | 60 (9.9) | 59 (8.8) | .83 |
|
| Spatial reasoning | 65 (17) | 65 (17) | 59 (20) | |
| |
|
| Drawing efficiency | 61 (8.4) | 61 (8.3) | 59 (9.2) | |
|
| Simple motor | 61 (6.7) | 61 (6.7) | 60 (7.4) | .80 |
|
| Information processing | 61 (11) | 61 (11) | 57 (11) | |
|
| Spatial reasoning | 67 (18) | 68 (17) | 62 (21) | .06 |
a MRI: magnetic resonance imaging.
b CMB: cerebral microbleed.
c t tests ( df =1018) were applied for continuous variable comparisons between 2 groups (cerebral microbleed versus no cerebral microbleed). χ 2 (female df =1, education df =2) tests were used for categorical variables, while Fisher exact tests were used in cases of low frequency. P values for statistical significance are shown.
d Significant P values are italicized.
e Due to the skewed distributions, we performed a Kruskal-Wallis rank sum test for the traditional clock-drawing test.
f DCT: digital clock-drawing test.
DCT | Lobar-only (n=46) | Deep-only (n=11) | Mixed (lobar+deep; n=7) |
| β (95% CI) | value | β (95% CI) | value | β (95% CI) | value |
Overall DCT score | 0.05 (–0.19 to 0.29) | .67 | –0.36 (–0.84 to 0.12) | .15 | –0.29 (–0.90 to 0.32) | .35 |
|
| Drawing efficiency | 0.20 (–0.05 to 0.45) | .12 | –0.65 (–1.15 to –0.15) | | –0.28 (–0.90 to 0.35) | .39 |
| Simple motor | 0.25 (–0.03 to 0.53) | .08 | –0.86 (–1.43 to –0.30) | | 0.52 (–0.19 to 1.23) | .15 |
| Information processing | 0.04 (–0.22 to 0.31) | .75 | –0.13 (–0.66 to 0.39) | .62 | –0.29 (–0.95 to 0.37) | .39 |
| Spatial reasoning | –0.06 (–0.30 to 0.18) | .60 | –0.12 (–0.59 to 0.35) | .60 | –1.70 (–2.29 to –1.11) | |
|
| Drawing efficiency | –0.18 (–0.45 to 0.09) | .19 | –0.05 (–0.57 to 0.47) | .86 | 0.05 (–0.60 to 0.71) | .88 |
| Simple motor | 0.08 (–0.20 to 0.36) | .57 | –0.18 (–0.73 to 0.38) | .54 | 0.48 (–0.22 to 1.18) | .18 |
| Information processing | –0.22 (–0.49 to 0.05) | .11 | –0.14 (–0.67 to 0.40) | .62 | –0.09 (–0.76 to 0.58) | .79 |
| Spatial reasoning | –0.01 (–0.29 to 0.26) | .92 | –0.22 (–0.77 to 0.32) | .43 | –0.16 (–0.85 to 0.52) | .64 |
a DCT: digital clock-drawing test.
b Significant P values are italicized.
This cross-sectional study in the FHS reveals the potential of the DCT as a cost-effective and objective screening tool for detecting CMB in different brain regions. Unlike the traditional CDT, the DCT offers detailed insights into cognitive function and demonstrates significant associations with CMB, particularly deep and mixed subtypes. The study highlights the limitations of traditional cognitive tests in detecting subtle brain abnormalities such as CMB and underscores the DCT’s value in early prediction of dementia risk.
Principal Findings
To our knowledge, our study is the first to evidence that the DCT reveals detailed, nuanced, and hidden information and can serve as a potentially useful screening tool to detect the presence of CMB in different brain regions. As CMB is a risk factor for AD [ 28 ] but is accompanied by no or very subtle clinical symptoms, it is costly for clinicians to use neuroimaging to detect CMB. In comparison, the DCT is more cost-effective and can be completed by patients within a couple of minutes with minimal assistance. Another advantage of the DCT is that it objectively captures detailed brain functions through automated digital collection and analysis, while the manual traditional counterpart depends on the subjective assessment by trained testers. Using the DCT may be useful for in future clinical practice for early screening and detection of CMB, triggering interventions that can delay the progress of the disease or prevent AD onset [ 35 ].
Comparison to Prior Work
Whereas the traditional CDT has low sensitivity and specificity to screen or diagnose participants with CMB, the DCT scores were significantly associated with CMB in our study, especially deep and mixed CMB, including across 3 different measurement levels (ie, overall score, domains, and facets of the DCT). Previous studies have reported inconsistent associations between CMB and the traditional CDT. For example, whereas 1 study found that CMB were a risk factor for low performance on the CDT [ 36 ], 2 others did not find a relationship [ 37 , 38 ]. Another study that did not exclude participants with dementia illustrated that lobar, but not deep, CMB were associated with CDT [ 39 ]. It is possible that CDT’s crude measurements contain mixtures of different cognitive functions that cannot be broken down into more detailed measurements such as facet scores of DCT and thus may not be able to clearly detect fine brain abnormalities like CMB.
Strengths and Limitations
There were several strengths in our study. First, in our study, the diagnostic discriminability using the DCT facet scores was able to differentiate those with and without CMB, especially the mixed subtype, independent from MCI. Second, the DCT is simple, can be self-administered, and could serve as a screening test before administering costly neuroimaging tests. Third, our study found that participants with lobar CMB and deep CMB had different DCT performance patterns. Whereas the command condition was more strongly associated with deep or mixed CMB, the copy condition may be more associated with lobar CMB. Since deep but not lobar CMB have been identified as risk factors for dementia development in previous studies [ 28 ], the DCT may be a valuable tool for the early prediction of dementia risk. By capturing multiple facets of cognitive function as well as their fine-grained interrelations, the DCT affords substantially more sensitive analyses compared to typical measures of domain-specific cognitive functions that are observed in isolation (or aggregated in sum scores that overlook fine-grained interrelations).
This study had several limitations. First, the sample size of deep and mixed CMB cases is relatively small, potentially limiting the generalizability of findings and statistical power to detect associations. Future studies should aim for larger and more diverse cohorts. Second, the associative study design restricts the ability to establish causal relationships between variables, despite efforts to control for confounding factors. Future research could benefit from longitudinal or interventional approaches to explore causality further. Lastly, the lack of diversity in the FHS cohort may limit the applicability of findings to broader populations. Future studies should strive to include more diverse cohorts to enhance generalizability and reduce potential biases.
Future Directions
Large cohorts with multiethnicities should be used to confirm that the DCT and other digital tools detect CMB and similar pathologies in different brain regions and can serve as a cost-effective screening tool to better identify people at risk earlier in the preclinical stages of the disease [ 11 ]. More importantly, user-oriented assessment devices such as the DCT may promote objectivity and equity within public health research, especially in underserved populations.
Acknowledgments
We thank Lilly Buck (MSc) and Leon Li (PhD) for their helpful feedback on an earlier draft of this paper. This work was supported by the National Heart, Lung, and Blood Institute contract (N01-HC-25195) and by grants from the National Institute of Neurological Disorders and Stroke (NS-17950) and the National Institute on Aging (AG-08122, 016495, 068753: RA, and AG-09899: WQQ).
Data Availability
The data sets generated or analyzed during this study are available through the Framingham Heart Study central database. For detailed information on data access, please visit the Framingham Heart Study Brain Aging Program (FHS-BAP) Data Access Portal [ 40 ].
Authors' Contributions
SCA-K and QT contributed equally to drafting this paper, study design, and data analysis. TFAA and WQQ contributed to the study design and substantial revision of this paper. RA contributed to the initiation of digital data collection in the Framingham Heart Study, data quality control, data sharing, and review and revision of this paper. CK managed digital data used in this study. ISI, DJL, MA, and JM contributed to the review and revision of this paper.
Conflicts of Interest
RA is a scientific advisor to Signant Health, Novo Nordisk, and Davos Alzheimer’s Collaborative. JM receives grants from the NIH (National Institutes of Health) and DOD (U.S. Department of Defense). All other authors have no conflict of interest to declare.
The descriptions of each subdomain of digital clock-drawing test (DCT) scores.
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Table of contents. Step 1: Restate the problem. Step 2: Sum up the paper. Step 3: Discuss the implications. Research paper conclusion examples. Frequently asked questions about research paper conclusions.
Research Paper Conclusion Examples; Summarizing Conclusion: Impact of social media on adolescents' mental health: In conclusion, our study has shown that increased usage of social media is significantly associated with higher levels of anxiety and depression among adolescents. These findings highlight the importance of understanding the ...
Here's an example of a research paper conclusion: Conclusion: In conclusion, our study aimed to investigate the relationship between social media use and mental health among college students. Our findings suggest that there is a significant association between social media use and increased levels of anxiety and depression among college students.
Step 1: Restate the problem. Always begin by restating the research problem in the conclusion of a research paper. This serves to remind the reader of your hypothesis and refresh them on the main point of the paper. When restating the problem, take care to avoid using exactly the same words you employed earlier in the paper.
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This article provides an effective technique for writing a conclusion adapted from Erika Eby's The College Student's Guide to Writing a Good Research Paper: 101 Easy Tips & Tricks to Make Your Work Stand Out.. While the thesis introduction starts out with broad statements about the topic, and then narrows it down to the thesis statement, a thesis conclusion does the same in the opposite order.
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The conclusion is intended to help the reader understand why your research should matter to them after they have finished reading the paper. A conclusion is not merely a summary of the main topics covered or a re-statement of your research problem, but a synthesis of key points derived from the findings of your study and, if applicable based on your analysis, explain new areas for future research.
The conclusion of a research paper is essential in tying together the different parts of the paper and offering a final perspective on the topic. It reinforces the main idea or argument presented and summarizes the key points and findings of the research, highlighting its significance. Additionally, the conclusion creates a full circle of the ...
Step 1: Answer your research question. Step 2: Summarize and reflect on your research. Step 3: Make future recommendations. Step 4: Emphasize your contributions to your field. Step 5: Wrap up your thesis or dissertation. Full conclusion example. Conclusion checklist. Other interesting articles.
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The conclusion is where you describe the consequences of your arguments by justifying to your readers why your arguments matter (Hamilton College, 2014). Derntl (2014) also describes conclusion as the counterpart of the introduction. Using the Hourglass Model (Swales, 1993) as a visual reference, Derntl describes conclusion as the part of the ...
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The point of a conclusion to a research paper is to summarize your argument for the reader and, perhaps, to call the reader to action if needed. 5. Make a call to action when appropriate. If and when needed, you can state to your readers that there is a need for further research on your paper's topic.
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Strong conclusion examples pave the way for the perfect paper ending. See how to write a good conclusion for a project, essay or paper to get the grade. Dictionary ... When it comes to a thesis or research paper conclusion example, it's important to end it on a high note. See a thesis conclusion example to get an idea for your thesis paper.
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A Research Paper Conclusion Poem is a literary flourish that serves as the concluding section of a research paper. Much like a poem, it weaves together the core el ements of your study into a harmonious symphony of words, aiming to resonate with your readers on a profound level. It goes beyond the traditional summarization, offering a creative ...
Research paper conclusion examples Make your conclusion concise and to-the-point, leaving the reader with a lasting message. Here are two examples: Example 1: Leadership This study explored how leadership influences organisational culture in three economic sectors: education, healthcare and finance. In each sector, we examined leadership in ...
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Background: Cerebral microbleeds (CMB) increase the risk for Alzheimer disease. Current neuroimaging methods that are used to detect CMB are costly and not always accessible. Objective: This study aimed to explore whether the digital clock-drawing test (DCT) may provide a behavioral indicator of CMB. Methods: In this study, we analyzed data from participants in the Framingham Heart Study ...
translate laws, policy papers, reports, correspondence, etc. drafted by or sent to the Commission; help the Commission communicate with the public, thereby helping citizens understand EU policies; edit original documents drafted by Commission authors; advise Commission departments on language and on managing multilingual websites