What to Do After a Low Clock Drawing Test Score

If you are reading this because you or someone you love just scored low on a clock drawing test, take a breath. A low score on a screening test is upsetting. It is also, by itself, not a diagnosis of anything. It is a flag — the kind that asks is this worth looking at more closely? — and the answer, often, is yes, but almost never in a panicked way.

This article is a practical walk-through of what to do next.

Start here: a low score is a screen, not a diagnosis

The clock drawing test is a screening tool. It was designed to catch possible cognitive concerns quickly, in a short visit or a few minutes at home, so that a more complete evaluation can follow. It is not designed to diagnose dementia, and the score on its own is not a medical opinion about you or your loved one. A low score means let's take a more careful look. It does not mean "you have dementia."

The clinical distinction matters because it changes what you should do. The right next step after a low screen is a calm conversation with a clinician, not an emergency. Rarely, a low score does accompany an emergency — we'll cover that at the end — but the vast majority of the time, the right response is to schedule a visit in the next week or two.

Reasons a person can score low that are not dementia

This list is not exhaustive. It is the short version of what an experienced clinician thinks about when the screen comes back low:

• Fatigue, dehydration, or a recent poor night of sleep. Cognition is notoriously sensitive to sleep deprivation. A test taken after a red-eye flight, a stressful day, or a bad night is not a test at baseline.
• Vision or motor problems. A hand tremor, arthritis, or failing eyesight can produce a messy drawing that has nothing to do with thinking.
• Depression or grief. In older adults particularly, depression can mimic dementia closely enough that the clinical pattern has a name: "pseudodementia." It reverses with depression treatment.
• Anxiety during the test. Performance anxiety alone can lower scores, especially in a person who believed this was an important or high-stakes evaluation.
• Medication side effects. Several common medications affect cognition. The biggest offenders are anticholinergic drugs (certain antihistamines, bladder medications, some sleep aids, some antidepressants), benzodiazepines, opioids, and combinations of multiple medications.
• Delirium from an acute illness. In older adults, urinary tract infections, pneumonia, and other acute infections famously cause abrupt confusion that resolves with treatment. Dehydration alone can do the same.
• Low formal education or unfamiliarity with analog clocks. The test assumes basic comfort with analog clock faces. A person who grew up on digital clocks, or who had limited formal schooling, may draw a less refined clock for reasons unrelated to their cognition.
• Language barrier. If the test was taken in a language the person is not fluent in, expect lower scores.

Many of these are things the person being screened may not think to mention. A clinician's first job after a low screen is to work through them systematically.

What to do next

Five concrete steps. In order of importance.

1. Schedule an appointment with a primary care physician

Not an emergency visit, unless the red flags at the end of this article are present. A regular office visit within the next one to two weeks is the right pace. The PCP can either run the full workup themselves or refer to a geriatrician, neurologist, or memory clinic — whichever fits your area and your insurance.

2. Bring a medication list

Write down every prescription medication, every over-the-counter medication (including sleep aids, cold medicines, and bladder medications), and every supplement. Include the dose. A medication review is one of the highest-yield parts of a cognitive workup.

3. Bring someone who knows the person well

One of the strongest signals in a cognitive evaluation is the account of a family member or friend who can compare what they're seeing now to the person's baseline. The patient often does not notice or report the changes themselves. If you are that family member — you are not intruding. You are part of the assessment.

4. Bring the drawing, or a photo of it

If the test was done on paper, photograph it. If it was done online, save the result. The clinician does not need your exact score — they need to see the drawing itself and the date it was done. The drawing tells a story that a single number doesn't.

5. Write down what you have noticed, with dates

Specificity helps. "Mom forgot how to get home from the grocery store on April 10" is more useful than "Mom seems forgetful." A short list of three to five concrete observations gives the clinician a timeline that would take a full appointment to tease out otherwise.

What the appointment usually looks like

The specifics vary by clinician and setting, but most first visits go something like this:

• A detailed history from the patient and from whoever came along. This is usually the longest part.
• A focused physical exam, including a brief neurological exam.
• A medication review.
• A repeat or expanded cognitive assessment. This is often the MoCA if the office is set up for it, or a Mini-Cog or MMSE if not. See MMSE vs Clock Drawing Test vs MoCA for how the tests differ.
• Blood work ordered the same day: complete blood count, basic metabolic panel, thyroid-stimulating hormone, vitamin B12, folate, and often vitamin D. Some clinicians add additional labs based on the history.
• A plan: whether to watch, whether to treat a reversible cause, whether to refer, whether to image.

Brain imaging — usually an MRI, sometimes a CT — is not always done on the first visit. It gets ordered when the history or exam raises a specific concern.

Questions worth asking at the appointment

Write these down ahead of time. Clinicians are used to these questions and appreciate patients who come prepared:

• Could any of my medications be affecting my thinking?
• What conditions other than dementia could cause this pattern?
• What tests would you recommend next, and what do they rule in or out?
• How soon should we expect results, and who will call me with them?
• Who else should be involved in this — a neurologist, a memory clinic, a social worker?
• What should we watch for in the meantime?
• If this turns out to be early dementia, what are the treatment and planning options?

Emotional and practical preparation

This is often the hardest part, and nobody prepares you for it.

Tell the people who need to know. If there is another family member sharing care responsibility — a spouse, a sibling, an adult child — this is the moment to include them. Alone is the worst way to go through this.

Expect a slower pace than you want. Cognitive workups usually take weeks to months from first visit to a clear picture. Labs come back. Imaging gets scheduled. A neuropsychology battery takes two to three hours and often has a waitlist. The temptation to push for answers faster is natural; it rarely changes anything useful.

Plan for the conversation about driving, finances, and legal matters. These do not need to happen on day one. They do need to happen within the first few months, while the person can participate in decisions. A durable power of attorney, advance directives, and a frank conversation about driving are the three that matter most.

Take care of yourself. If you are the family member carrying this, the next months will be harder on you than you expect. Caregiver burnout is a clinical entity, not a figure of speech. A therapist, a support group, or a long walk with a friend who will just listen — each of these is a real intervention.

What not to do

• Don't self-diagnose from the internet. This article included. A screening result plus a Google search produces more anxiety than insight. The clinician's assessment is what matters.
• Don't change or stop medications without talking to a clinician. Some medications that could be affecting cognition are also medications that need to be tapered carefully.
• Don't conceal the result from family who share care responsibility. Even if the person prefers privacy, people with a direct stake in their safety — driving, medication adherence, falls — need to be included.
• Don't assume nothing can be done. Even when the diagnosis is true dementia, early interventions — medications, lifestyle modifications, caregiver support, safety planning — work better the sooner they start.

When to not wait

A cognitive workup is usually routine and unhurried. A small set of presentations, however, are medical urgencies and belong in an emergency department today, not a memory clinic next month:

• Sudden confusion that started over hours or days, rather than weeks to months. This is delirium or acute encephalopathy until proven otherwise, and it usually has a treatable cause.
• Sudden weakness or numbness, especially on one side of the body.
• Sudden trouble speaking, trouble understanding speech, or a dramatic vision change.
• A new severe headache, especially if the person describes it as "the worst of my life."
• A recent head injury, even a minor-seeming one, followed by new confusion.
• Fever with confusion, especially in an older adult.

If any of these are present, call 911 or go to the nearest emergency department. The clock drawing test in these situations is not the tool that matters.

Resources

• Alzheimer's Association Helpline: 1-800-272-3900. Free, available 24 hours a day, staffed by clinicians and social workers. Good for both medical questions and caregiver support.
• Your local Area Agency on Aging. Can help with caregiving resources, in-home services, and financial planning.
• Primary care physician's office. Often underused. Your PCP can answer many of the early questions and save you the stress of scheduling specialists first.

Related reading

• The Clock Drawing Test: Complete Scoring and Interpretation Guide
• Early Signs of Dementia vs Normal Aging: A Guide for Families
• MMSE vs Clock Drawing Test vs MoCA: Which Cognitive Screening Should You Take?

References

• Alzheimer's Association. Helpline and Support Resources. alz.org.
• American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081.
• Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. The Lancet. 2014;383(9920):911–922.

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Disclosure: Dr. Shimada is the founder of Tokei Health. This article is informational and is not a substitute for individual medical advice from your own clinician.