Secondary Logo

Journal Logo

Usefulness of Cube Copying in Evaluating Clinical Profiles of Patients with Parkinson Disease

Bu, Xiao-Yun MS*; Luo, Xiao-Guang PhD, MD*,†; Gao, Chao MS*; Feng, Yu PhD, MD*; Yu, Hong-Mei PhD, MD*; Ren, Yan PhD, MD*; Shang, Hong PhD, MD; He, Zhi-Yi PhD, MD*

Cognitive And Behavioral Neurology: September 2013 - Volume 26 - Issue 3 - p 140–145
doi: 10.1097/WNN.0000000000000006
Original Studies

Objective: To clarify the relationship between the quantitatively assessed cube-copying test (CCT) and clinical profiles of cognitive and motor ability in Chinese patients with Parkinson disease (PD).

Methods: We gave the Montreal Cognitive Assessment (MoCA), which includes the CCT, to evaluate the cognitive function of 102 outpatients with PD. We also gave the Unified Parkinson’s Disease Rating Scale (UPDRS) II and III and the Hoehn-Yahr scale to evaluate the patients’ motor function and disease severity, respectively. We used Maeshima’s method for quantitative assessment of the CCT, and calculated CCT errors by adding incomplete connections and plane-drawing errors. We divided the patients into 2 groups based on normal (no errors) versus abnormal (≥1 errors) CCT scores.

Results: We found 34 patients with normal scores and 68 with abnormal scores. The 2 groups had significant differences in age of onset, MoCA score, UPDRS II and III scores, and cognitive deterioration rate. CCT errors correlated inversely with cognitive domains except for orientation. Executive function was most commonly affected in both groups. We found correlations between numbers of CCT errors and left-limb movement, fine hand movement, postural instability and gait disorders, UPDRS II and III scores, and cognitive and motor deterioration rates.

Conclusions: The quantitatively assessed CCT may be useful in estimating cognitive and motor dysfunction in patients with PD, and in monitoring disease progression.

Departments of *Neurology

Laboratory Medicine, First Affiliated Hospital of China Medical University, Shenyang, China

This work was funded by the National Nature Science Fund of China (No. 81371421, 30973153, 8141070, and 81000623), Liaoning Young Scholar Sponsor Plan (LJQ 2011081), and the Foundation of the Liaoning Educational Committee (L202013136, L2010560).

The authors declare no conflicts of interest.

Reprints: Xiao-Guang Luo, PhD, MD, Department of Neurology, First Affiliated Hospital of China Medical University, 155# Nanjing Bei Street, Heping District, Shenyang, China 110001 (e-mail:

Received September 25, 2012

Accepted August 1, 2013

Reader Benefit: The quantitatively assessed cube-copying test may be useful in estimating cognitive and motor dysfunction in patients with Parkinson disease, and in monitoring disease progression.

CCT=cube-copying test; MoCA=Montreal Cognitive Assessment; PD=Parkinson disease; UPDRS=Unified Parkinson’s Disease Rating Scale.

Parkinson disease (PD) is a neurodegenerative disorder that manifests clinically with resting tremors, rigidity, bradykinesia, postural instability, and cognitive impairment (Haas et al, 2012). Approximately 24% to 31% of patients with PD have been diagnosed as suffering from dementia (Aarsland et al, 2005). Longitudinal studies suggest that up to 78% of patients with PD will develop dementia after exhibiting nearly 2 decades of motor symptoms (Aarsland et al, 2003).

The cube-copying test (CCT) is reported to be a more sensitive examination for detecting cognitive ability than are non-cube 2-dimensional figure-drawing tests (Ericsson et al, 1996; Griffiths et al, 1988). The CCT is a brief and convenient examination that can be easily performed and quantitatively assessed. Poor CCT performance has been identified as a risk factor for mild cognitive impairment in patients who later develop Alzheimer disease or another form of dementia (Maeshima et al, 2004). In PD, the CCT may also reflect the examinee’s cognitive function (Maeshima et al, 1997). However, until now patients with PD had not been evaluated for the relationship between the CCT and comprehensive clinical profiles of cognitive and motor ability, as well as disease progression.

In this study, we used the Montreal Cognitive Assessment (MoCA), a validated and sensitive measure of cognitive assessment in persons with PD (Hoops et al, 2009); the Unified Parkinson’s Disease Rating Scale (UPDRS) sections II and III, an examination for motor function; and a modified scoring guideline to assess the CCT quantitatively in an effort to evaluate the relationship between the CCT and clinical profiles of patients with PD.

Back to Top | Article Outline



Between April and November 2010, we identified potential participants who presented at the Parkinson Disease Outpatient Center of the First Affiliated Hospital of China Medical University (Shenyang, China) with suspected idiopathic PD and were diagnosed according to the UK Parkinson’s Disease Society Brain Bank Clinical Diagnostic Criteria (Hughes et al, 1992). For all potential participants, we obtained demographic and clinical information, including age, sex, disease duration years, symptoms at onset, and neuropsychological and motor function test results. We gave the 17-item Hamilton scale (Fleck et al, 2004) to identify depression and measure the severity of symptoms; we excluded from the study 15 patients whom we considered to have at least moderate depression because they scored >15 on the Hamilton scale.

We enrolled 102 patients in the study. We gave them sections II and III of the UPDRS to assess their motor ability, the Hoehn-Yahr scale to determine their disease stage, and the MoCA to assess their cognitive function. The CCT is part of the MoCA. The patients performed the CCT only once. They were not given a time limit. Although they were free to use their preferred hand, all of them used their right hand. Most left-handed people in China are taught to write and draw with their right hand.

All patients gave written informed consent, and the hospital’s Ethics Review Board approved the study protocol.

Back to Top | Article Outline

CCT Quantitative Assessment

We used Maeshima’s method (Buchhave et al, 2008; Maeshima et al, 1997; Maeshima et al, 2002; Maeshima et al, 2004; Palmqvist et al, 2008) for quantitative assessment of the CCT (Figure 1). Participants can make 2 kinds of errors on the CCT. A connection error can be made at any of the 8 points in a drawn cube where 3 lines meet to form a vertex; we considered lines more than 3 mm off the point to be inaccurate. A plane-drawing error can be made in the number of lines drawn and the extent to which they are parallel; to determine these errors, we evaluated each plane, defined by 2 pairs of parallel lines.



In Maeshima’s own works, both plane-drawing and connection-point scores have significant correlation with performance in “block design,” which measures visuospatial and motor skills (Maeshima et al, 1997; Maeshima et al, 2002). Maeshima also found a close relation between connection errors and plane-drawing errors; both types of errors indicate the same type of underlying dysfunction.

For this reason, we calculated the CCT error score by adding the number of connection errors and the number of plane-drawing errors. We classified a score of 0 as “normal” (a completely accurate drawing), indicating an intact constructional ability, and a score of >0 as “abnormal,” suggesting impaired constructional ability. The worst possible score of 20 would mean that a drawing had none of the required 12 lines or 8 connection points (Figure 1).

Back to Top | Article Outline

Cognitive and Motor Assessment

Because the MoCA’s cutoff score for normal cognition is 26, we used the following formula, as previously described (Luo et al, 2010), to assess the cognitive deterioration rate:

Our formula for the motor function deterioration rate was:

We defined the cognitive domains tested by the MoCA as follows (Harkness et al, 2011; McLennan et al, 2011; Nazem et al, 2009): visuospatial abilities (including clock drawing and cube copying), memory (including the 5-word delayed free recall), executive function (including line, verbal fluency, and abstraction tasks), attention (including alertness, serial calculation, and digit recitation and reverse recitation), language (including picture naming and sentence repetition), and orientation (including recall of time and place).

Because the cutoff values for each MoCA subscore are arbitrary, we established our cutoff values using the scores of a control group from another, parallel study (Luo et al, 2010). If patients scored 1.5 standard deviations below the mean subscore value for age- and education-matched controls, we considered them to be impaired in that domain (Luo et al, 2010; Mamikonyan et al, 2009). Because only integers ≥0 can be recorded for each item, we considered patients to have cognitive impairment if they scored ≤1 for the visuospatial domain, ≤4 for attention, 0 for memory, ≤1 for executive function, and ≤2 for language.

Back to Top | Article Outline

Statistical Analysis

We used SPSS 17.0 (SPSS, Chicago, IL) software for statistical analyses. We used a Mann-Whitney U test to assess the significance of the differences between the 2 groups. We used χ2 analysis to test group differences found within the categorical data. We calculated Spearman rank correlation coefficients to determine the relationship between the quantitative assessment of constructional ability and each clinical feature. We considered a P value <0.05 to be statistically significant.

Back to Top | Article Outline


Comparison of the Normal Versus Abnormal CCT Groups

Table 1 presents our 102 patients’ demographic features and clinical profiles. We divided the patients into 2 groups by their CCT scores: 34 (33.3%) with normal scores (no errors) and 68 (66.7%) with abnormal scores (≥1 error). The patients with abnormal CCT scores had significantly lower MoCA scores (P<0.001) and significantly higher cognitive deterioration rate scores (P<0.001) and UPDRS II and III motor scores (P=0.034). The abnormal CCT group was also significantly older (P=0.010). The 2 groups did not differ significantly by sex, duration of disease, or motor deterioration rate.



The patients with an abnormal CCT tended to exhibit more severe PD symptoms, as suggested by their Hoehn-Yahr stage (P=0.061). We did not find significant differences between the 2 groups for motor laterality and symptoms at onset (tremor vs rigidity), motor subtype (tremor-predominant vs postural instability and gait disorder-predominant) (Alves et al, 2006), or the predominant side (Nys et al, 2010) as determined by the UPDRS (data not shown).

The average scores of most MoCA subitems were significantly lower in the abnormal CCT group (P<0.05), the exceptions being recitation, verbal fluency, repeat, and orientation (Table 2). To investigate the relationship between the CCT and comprehensive cognition, we studied the correlation between CCT errors and each cognitive domain (Table 3). We found a significant negative correlation between CCT errors and all cognitive domains except orientation. We found a significant positive correlation between CCT errors and the cognitive deterioration rate.





Back to Top | Article Outline

Analyses of Cognitive Impairment Subtypes

Table 4 shows the subtypes of cognitive impairment by CCT group. In the normal group, we found cognitive impairment in 9 patients (26.5%) in a single domain and in 6 (17.6%) patients in multiple domains. In the abnormal CCT group, we found cognitive impairment in 16 patients (23.5%) in a single domain and in 46 (67.6%) patients in multiple domains. There was a significant difference in the proportion of single- or multiple-domain cognitive impairment between the 2 CCT groups (P<0.05), with much more multiple-domain cognitive impairment in the abnormal group.



Executive function was most commonly involved in either single- or multiple-domain cognitive impairment in both groups. Neither group had single-domain cognitive impairment of language, visuospatial abilities, or attention, suggesting that these domains are most likely not involved in early-stage PD.

Back to Top | Article Outline

Correlation of CCT with Motor Ability as Evaluated with the UPDRS

CCT errors correlated highly with cognitive deterioration rate, motor disability assessed by UPDRS II and III, and motor deterioration rate. Moreover, we found a positive correlation between CCT errors and the score on some subitems in the UPDRS examination, including “arising from chair,” “posture,” “gait,” and “body bradykinesia,” as well as a composite score for postural instability and gait disorder, indicating that a higher CCT error score represents a higher level of motor dysfunction. Interestingly, we also found a moderate but significant relationship between CCT errors and impaired performance by the left limbs (including left finger taps, left-hand movements, and left-leg agility) and fine hand movement (Table 5).



Back to Top | Article Outline


We used a quantitative assessment of the CCT to see whether test performance reflects the cognitive and motor profiles of patients with PD. Our results showed that patients with abnormal CCT performance had poor cognitive function, impaired motor ability, and a higher cognitive deterioration rate. We believe that the simple CCT may be predictive of the cognitive and motor profiles of patients with PD.

Our patients with an abnormal CCT had a higher cognitive deterioration rate and were significantly older at disease onset than those with a normal CCT. This finding is consistent with our previous study that reported greater susceptibility to cognitive impairment in patients who were older at PD onset (Luo et al, 2010). In this study, the MoCA score and, in particular, many of its subitem scores were significantly higher in our normal than our abnormal CCT group. Not surprisingly, we found the most prominent differences in subitems involving lines, most likely because both the CCT and other line tasks involve both visuospatial and executive components.

At the same time, we found a significant inverse correlation between CCT errors and cognitive domains other than orientation, as shown in Table 3. Confirming other research (Metzler-Baddeley, 2007; Palmqvist et al, 2009), our finding suggests strong consistency between the CCT and the general cognitive profiles of examinees with PD.

Thus, the CCT may provide an estimate of the occurrence or severity of cognitive impairment. Given that we found no significant difference between disease duration and disease severity as assessed by the Hoehn-Yahr stages, an abnormal CCT might signal a subset of patients who have faster cognitive deterioration and multiple-domain cognitive impairment at an earlier stage of PD.

To determine whether CCT errors were related to specific motor symptoms in our patients, we analyzed the correlation between the CCT error rate and each subitem under UPDRS II and III. Not surprisingly, we found a significant correlation between CCT performance and impaired limb movement on the left side, including finger taps, hand movement, and leg agility (Table 5). The more impaired the left-limb movement, the more CCT errors we found, indicating an association between left-sided motor symptoms and visuospatial impairment in PD.

Traditionally, it has been thought that the right hemisphere is specialized for visuospatial processing. This belief is consistent with our findings: Impaired left-sided motor function might be affected by a defect in the right hemisphere and thus impair visuospatial ability during the CCT (Corballis, 2003). Cooper et al (2009) found a significant association between right-sided motor impairment and verbal memory, visuoperceptual skills, and verbal fluency in patients with PD, while left-sided motor symptoms were not related to any cognitive domains. The lack of investigation into a specific cognitive ability, such as the visuospatial domain, may explain the different outcomes between our studies.

We also found a significant correlation between CCT errors and right- and left-handed dexterity, including finger taps and fine hand movements. Physical activities have been connected with cognitive ability (Scherder et al, 2005), and, in an aging population, higher levels of physical activity are linked to enhanced cognitive function. Hand movements activate not only the primary motor and cingulate cortices (Paus et al, 1993) but also other brain areas used in cognition (Iacoboni et al, 2001), eg, the superior temporal sulcus, which is involved in facial recognition (Haxby et al, 2000). This sulcus is connected to the prefrontal cortex, an area central to cognition, especially executive function (Petrides and Pandya, 2006).

Eggermont et al (2009) investigated the relationship of hand movements to cognition and mood in people with dementia. The authors found a positive effect between a hand movement program and mood, and suggested that these effects might have broader implications. By activating certain neural circuits, hand movements may affect cognition and emotion. However, there have been few reports about this relationship in patients with PD. Our finding of an association between hand motor activity and CCT errors indicates potential for improving cognition in patients with PD by promoting hand exercise.

In our study, CCT errors also correlated with the postural instability and gait disorder score, UPDRS II and III motor scores, and motor deterioration rate. These results were consistent with other studies of cognitive impairment in PD in associating older age, later disease onset, and more severe motor symptoms with a higher risk of cognitive impairment (Aarsland et al, 2001; Emre et al, 2007; Hobson and Meara, 2004; Hughes et al, 2000).

We also found that executive function was most commonly affected in either single- or multiple-domain cognitive impairment in both the normal and abnormal CCT groups, suggesting that executive function may be the earliest domain affected by PD—and the most vulnerable cognitive domain. Our findings that executive function is most commonly impaired in patients with PD is also consistent with previous studies (Caviness et al, 2007; Mosimann et al, 2004; Muslimovic et al, 2005).

Neither of our groups had single-domain cognitive impairment of language, visuospatial abilities, or attention, suggesting a low probability that these domains are involved at an early stage of PD.

Our study design had some limitations. First, compared with more formal and time-consuming cognitive tests, the MoCA provides only a relatively rough estimate that may not fully and accurately assess a person’s cognitive state. Second, we cannot completely rule out the possibility that our patients had some other form of dementia, such as Alzheimer disease, in addition to PD. Third, the cognitive deterioration rate and motor deterioration rate are defined retrospectively as average speeds of decline, relative to disease duration; these calculations are considered inferior to data collected during a prospective longitudinal study. Finally, the cutoff values of MoCA subscores that we borrowed from another, parallel study were derived from a small population, which limited their power to serve as normative values.

Nevertheless, our results indicate that the CCT may be a clinically fast and useful way to assess cognitive and motor dysfunction in patients with PD and may aid in both determining prognosis and monitoring disease progression.

Back to Top | Article Outline


Aarsland D, Andersen K, Larsen JP, et al..Risk of dementia in Parkinson’s disease: a community-based, prospective study.Neurology.2001;56:730–736.
Aarsland D, Andersen K, Larsen JP, et al..Prevalence and characteristics of dementia in Parkinson disease: an 8-year prospective study.Arch Neurol.2003;60:387–392.
Aarsland D, Zaccai J, Brayne C.A systematic review of prevalence studies of dementia in Parkinson’s disease.Mov Disord.2005;20:1255–1263.
Alves G, Larsen JP, Emre M, et al..Changes in motor subtype and risk for incident dementia in Parkinson’s disease.Mov Disord.2006;21:1123–1130.
Buchhave P, Stomrud E, Warkentin S, et al..Cube copying test in combination with rCBF or CSF A beta 42 predicts development of Alzheimer’s disease.Dement Geriatr Cogn Disord.2008;25:544–552.
Caviness JN, Driver-Dunckley E, Connor DJ, et al..Defining mild cognitive impairment in Parkinson’s disease.Mov Disord.2007;22:1272–1277.
Cooper CA, Mikos AE, Wood MF, et al..Does laterality of motor impairment tell us something about cognition in Parkinson disease?Parkinsonism Relat Disord.2009;15:315–317.
Corballis PM.Visuospatial processing and the right-hemisphere interpreter.Brain Cogn.2003;53:171–176.
Eggermont LH, Knol DL, Hol EM, et al..Hand motor activity, cognition, mood, and the rest-activity rhythm in dementia: a clustered RCT.Behav Brain Res.2009;196:271–278.
Emre M, Aarsland D, Brown R, et al..Clinical diagnostic criteria for dementia associated with Parkinson’s disease.Mov Disord.2007;22:1689–1707.
Ericsson K, Forssell LG, Holmen K, et al..Copying and handwriting ability in the screening of cognitive dysfunction in old age.Arch Gerontol Geriatr.1996;22:103–121.
Fleck MP, Chaves ML, Poirier-Littre MF, et al..Depression in France and Brazil: factorial structure of the 17-item Hamilton Depression Scale in inpatients.J Nerv Ment Dis.2004;192:103–110.
Griffiths KM, Cook ML, Newcombe RL.Cube copying after cerebral damage.J Clin Exp Neuropsychol.1988;10:800–812.
Haas BR, Stewart TH, Zhang J.Premotor biomarkers for Parkinson’s disease—a promising direction of research.Transl Neurodegener.2012;1:11.
Harkness K, Demers C, Heckman GA, et al..Screening for cognitive deficits using the Montreal Cognitive Assessment tool in outpatients ≥65 years of age with heart failure.Am J Cardiol.2011;107:1203–1207.
Haxby JV, Hoffman EA, Gobbini MI.The distributed human neural system for face perception.Trends Cogn Sci.2000;4:223–233.
Hobson P, Meara J.Risk and incidence of dementia in a cohort of older subjects with Parkinson’s disease in the United Kingdom.Mov Disord.2004;19:1043–1049.
Hoops S, Nazem S, Siderowf AD, et al..Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease.Neurology.2009;73:1738–1745.
Hughes AJ, Daniel SE, Kilford L, et al..Accuracy of clinical diagnosis of idiopathic Parkinson’s disease: a clinico-pathological study of 100 cases.J Neurol Neurosurg Psychiatry.1992;55:181–184.
Hughes TA, Ross HF, Musa S, et al..A 10-year study of the incidence of and factors predicting dementia in Parkinson’s disease.Neurology.2000;54:1596–1602.
Iacoboni M, Koski LM, Brass M, et al..Reafferent copies of imitated actions in the right superior temporal cortex.Proc Natl Acad Sci USA.2001;98:13995–13999.
Luo XG, Feng Y, Liu R, et al..Cognitive deterioration rates in patients with Parkinson’s disease from northeastern China.Dement Geriatr Cogn Disord.2010;30:64–70.
Maeshima S, Itakura T, Nakagawa M, et al..Visuospatial impairment and activities of daily living in patients with Parkinson’s disease: a quantitative assessment of the cube-copying task.Am J Phys Med Rehabil.1997;76:383–388.
Maeshima S, Osawa A, Maeshima E, et al..Usefulness of a cube-copying test in outpatients with dementia.Brain Inj.2004;18:889–898.
Maeshima S, Ueyoshi A, Matsumoto T, et al..Quantitative assessment of impairment in constructional ability by cube copying in patients with aphasia.Brain Inj.2002;16:161–167.
Mamikonyan E, Moberg PJ, Siderowf A, et al..Mild cognitive impairment is common in Parkinson’s disease patients with normal Mini-Mental State Examination (MMSE) scores.Parkinsonism Relat Disord.2009;15:226–231.
McLennan SN, Mathias JL, Brennan LC, et al..Validity of the Montreal Cognitive Assessment (MoCA) as a screening test for mild cognitive impairment (MCI) in a cardiovascular population.J Geriatr Psychiatry Neurol.2011;24:33–38.
Metzler-Baddeley C.A review of cognitive impairments in dementia with Lewy bodies relative to Alzheimer’s disease and Parkinson’s disease with dementia.Cortex.2007;43:583–600.
Mosimann UP, Mather G, Wesnes KA, et al..Visual perception in Parkinson disease dementia and dementia with Lewy bodies.Neurology.2004;63:2091–2096.
Muslimovic D, Post B, Speelman JD, et al..Cognitive profile of patients with newly diagnosed Parkinson disease.Neurology.2005;65:1239–1245.
Nazem S, Siderowf AD, Duda JE, et al..Montreal Cognitive Assessment performance in patients with Parkinson’s disease with “normal” global cognition according to Mini-Mental State Examination score.J Am Geriatr Soc.2009;57:304–308.
Nys GM, Santens P, Vingerhoets G.Horizontal and vertical attentional orienting in Parkinson’s disease.Brain Cogn.2010;74:179–185.
Palmqvist S, Hansson O, Minthon L, et al..The usefulness of cube copying for evaluating treatment of Alzheimer’s disease.Am J Alzheimers Dis Other Demen.2008;23:439–446.
Palmqvist S, Hansson O, Minthon L, et al..Practical suggestions on how to differentiate dementia with Lewy bodies from Alzheimer’s disease with common cognitive tests.Int J Geriatr Psychiatry.2009;24:1405–1412.
Paus T, Petrides M, Evans AC, et al..Role of the human anterior cingulate cortex in the control of oculomotor, manual, and speech responses: a positron emission tomography study.J Neurophysiol.1993;70:453–469.
Petrides M, Pandya DN.Efferent association pathways originating in the caudal prefrontal cortex in the macaque monkey.J Comp Neurol.2006;498:227–251.
Scherder EJ, Van Paasschen J, Deijen JB, et al..Physical activity and executive functions in the elderly with mild cognitive impairment.Aging Ment Health.2005;9:272–280.

Parkinson disease; cube-copying test; cognitive function; motor function

© 2013 by Lippincott Williams & Wilkins.