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Poppelreuter figure

z Original research

The Poppelreuter figure visual perceptual

function test for dementia diagnosis
Rebecca Sells, Andrew J Larner MRCP

The Poppelreuter figure is a simple test of visual perceptual function consisting of four
overlapping images. This study investigates its utility for the diagnosis of dementia in a
cognitive function clinic.

he many cognitive screening

instruments in existence may
be broadly classified as scales that
test either general or specific cognitive functions. 1 The former,
including the Mini-Mental State
Examination (MMSE), 2 the
Addenbrookes Cognitive Examination (ACE) 3 and its revision
(ACE-R), 4 and the Montreal
Cognitive Assessment (MoCA), 5
have been used most widely in the
assessment of patients with possible dementia. However, scales that
test a specific cognitive function,
such as memory,6 may also have a
place in clinical practice, since
these tests are usually very short,
some requiring only one or two
questions.7-9
Visual perceptual deficits may
be a feature of various dementia
syndromes, including Alzheimers
disease, especially in its visual variant, also known as posterior cortical atrophy, 10 in Parkinsons
disease dementia and dementia
with Lewy bodies, and in prion disorders. Frontotemporal lobar
degenerations, by contrast, classically spare visual perceptual function, although Luria noted that
patients with frontal lobe lesions
were characterised by persistent
inert attention to only one detail
of a pattern, reflecting an inability to move from one component
to another as easily as they
should.11
The MMSE is recognised to
lack a specific test of visual percepwww.progressnp.com

tual function, the intersecting

pentagons being a test of visuo motor or visuoconstructional
function. This is also true of the
ACE (Necker cube, clock drawing) and the visuospatial/executive tests in the MoCA. The
ACE-R, however, has specific visual
perceptual tasks (dot counting,
fragmented letters).
Overlapping figures used in the
assessment of visual perceptual
deficits comprise two or more line
drawings that partly overlap.12 The
German neuropsychiatrist Walter
Poppelreuter (1886-1939)13 produced one example of overlapping
figures (see Figure 1),14 as part of
his interest in the study of visual
neglect, which he believed was a
form of inattention. 15 The
Poppelreuter figure, sometimes
known as the Ghent or
Poppelreuter-Ghent figure, may be
characterised (in Gestalt terms) as
a figure/ground discrimination
task, which is acknowledged to be
problematic for patients with
apperceptive (but not associative)
visual agnosia, especially dorsal
simultanagnosia, usually associated
with right posterior hemisphere
lesions.16,17
Despite its antiquity, the clinical utility of the Poppelreuter figure, as opposed to its value in
neuropsychological studies, has
seldom been examined. In a
group of 12 Alzheimers disease
patients, Della Sala et al. found
that performance was impaired

Figure 1. The Poppelreuter figure, consisting of four overlapping

images, is a simple test of visual perceptual function

using their overlapping figure

paradigm, principally at the figure
discrimination stage, and concluded that the Poppelreuter figure was a sensitive tool to detect
visuospatial deficits. By contrast,
the only errors made by healthy
individuals were omissions.18
The aim of this study was to
assess the utility of the
Poppelreuter figure for the diagnosis of dementia in day-to-day
clinical practice in the setting of a
dedicated cognitive function
clinic, using both retrospective and
prospective assessments.
Patients and methods
The retrospective part of the study
was performed by examining the
notes of 50 patients administered
the Poppelreuter figure from 2001-

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Poppelreuter figure

2002. In the prospective part of the

study, consecutive new patient
referrals were recruited over a sixmonth period (March-September
2010). In both parts of the study,
standard clinical diagnostic criteria were used for the diagnosis of
dementia (DSM-IV) and dementia
subtypes, as previously described.19
As the prospective evaluation was
a pragmatic assessment, patients
were selected as they presented to
the cognitive function clinic, not
according to diagnosis. Diagnosis
was by the judgement of an experienced clinician based on diagnostic criteria.
In both the retrospective and
prospective assessments, patients
were shown the Poppelreuter figure
(black and white line drawing,
image size 9cm x 9cm; see Figure 1),
always presented initially in the
same orientation (namely with the
jug vertical), independent of, but
on the same day as, clinical and neuropsychological assessment. The
Poppelreuter figure test was scored
(range 0-4) according to the
patients ability to identify, not to
name, the individual elements (jug,
cleaver, iron, hammer). Points were
deducted for omissions, but not for
false alarms, ie naming items not
present. Poppelreuter scores were
not used in the diagnostic judgment
of dementia/no dementia in order
to minimise review bias.20
Other tests administered were
the MMSE, 2 ACE 3 (2001-2002
study only), and the two tests of
visual perceptual abilities from the
ACE-R4 (2010 study only), namely
counting of dot arrays and identification of fragmented letters.
Correlations were calculated
between the scores for the
Poppelreuter figure and total
MMSE score (range 0-30), MMSE
intersecting pentagons (0-1), ACE
total score (0-100), ACE-R dot
counting (0-4), and ACE-R fragmented letters (0-4). Standard
18

Demographics:

Retrospective
cohort (2001-2002)

Prospective cohort
(March-September 2010)

Number

50

101

M:F ratio

35:15 (70% male)

53:48 (52 % male)

Age range

41-82 years,
median 60 years

23-89 years,
median 61 years

Dementia:no
dementia ratio

28:22 (dementia
prevalence = 56%)

28:73 (dementia
prevalence = 28%)

Alzheimers disease

20 (1 posterior
cortical atrophy)

15 (2 posterior cortical
atrophy)

Frontotemporal
lobar degeneration

Dementia with
Lewy bodies/
Parkinsons disease
dementia

Others

Dementia diagnoses

Table 1. Demographics and diagnoses of the patients in the retrospective and prospective
cohorts

summary measures of diagnostic

utility (for dementia vs no dementia) were generated for Poppel reuter figure scores; namely,
sensitivity, specificity, Youden
index, positive and negative predictive values (PPV, NPV), diagnostic odds ratio, positive and negative
likelihood ratios (LR+ and LR-),
positive and negative utility index
(UI+, UI-),21 and receiver operating characteristic (ROC) cur ve.
The Standards for the Reporting
of Diagnostic Accuracy (STARD)
guidelines on reporting diagnostic
test accuracy were observed.22
Results
Retrospective cohort
Overall, 50 patients were assessed
with the Poppelreuter figure, of
whom 28 (56 per cent) had
dementia by DSM-IV criteria (see
Table 1, left-hand column, for

Progress in Neurology and Psychiatry

demographics and diagnoses). No

record of patient acceptability
of the Poppelreuter figure was
recorded in the notes.
Poppelreuter scores ranged
from 0-4. For the group with
dementia, the mode, median and
mean Poppelreuter scores were 4,
4, and 3.50 0.72, respectively. All
the patients without dementia
scored 4. The mean Poppelreuter
scores differed significantly between
the groups with and without dementia (t = 3.09, df = 42, p < 0.01).
There was a weak negative
correlation between age and
Poppelreuter score (r = -0.23).
Correlations between Poppel reuter score and the other tests
showed a high correlation only for
intersecting pentagons score (r =
0.80, p < 0.001), the other correlations being low (MMSE: r = 0.26,
p < 0.05; ACE: r = 0.23, p < 0.05).
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Poppelreuter figure

Test accuracy
Sensitivity
Specificity
Youden index (sens + spec - 1)
Positive predictive value (PPV)
Negative predictive value (NPV)
Diagnostic Odds Ratio
Positive likelihood ratio (LR+)
Negative likelihood ratio (LR-)
Utility index (UI+)
Utility index (UI-)
Area under ROC curve

Retrospective
cohort
(2001-2002)

Prospective
cohort (MarchSeptember 2010)

0.66 (0.52-0.80)
0.38 (0.18-0.57)
1.00
0.38
1.00
0.57 (0.41-0.74)

0.63 (0.37-1.05)
0.38 (poor)
0.57 (satisfactory)
0.69 (0.59-0.79)

0.72 (0.64-0.81)
0.39 (0.21-0.57)
0.85 (0.77-0.93)
0.24
0.50 (0.29-0.71)
0.78 (0.69-0.88)
3.65 (1.79-7.44)
2.61 (1.28-5.32)
0.71 (0.35-1.46)
0.20 (very poor)
0.67 (good)
0.63 (0.53-0.74)

Table 2. Diagnostic parameters for Poppelreuter test at cutoff 3/4 (with 95% confidence
intervals)

Optimal test sensitivity for the

differential diagnosis of dementia/not dementia in this cohort
was found to be 0.38 at the
Poppelreuter cutoff of 3/4, and
optimal test specificity was 1.00 at
the same cutoff, with test accuracy
of 0.66. Traditional parameters of
test diagnostic utility at the 3/4
cutoff are shown in Table 2 (lefthand column).
Prospective cohort
Over the study period, 101 patients
were assessed of whom 28 (28 per
cent) had dementia as assessed by
DSM-IV criteria (see Table 1, right
hand column, for demographics
and diagnoses). The Poppelreuter
figure proved acceptable to
patients and easy to use, being
completed in less than one minute
by all patients.
Poppelreuter scores ranged
from 0-4. For the group with
dementia, the mode, median and
mean Poppelreuter scores were 4,
4, and 3.32 1.09, respectively; for
the group without dementia the
mode, median, and mean scores
were 4, 4, and 3.85 0.36. The
mean Poppelreuter scores differed
significantly between the groups
20

with and without dementia

(t = 3.67, df = 99, p < 0.001).
There was a very weak negative
correlation between age and
Poppelreuter score (r = -0.13).
Correlations between Poppel reuter score and the other specific
(dot counting, fragmented letters,
intersecting pentagons) and general (MMSE) tests were moderate
or high for other visual perceptual
tasks (dot counting: r = 0.56,
p < 0.001; fragmented letters:
r = 0.71, p < 0.001) and poor for
the visuomotor task (intersecting
pentagons: r = 0.23, p < 0.05) and
for MMSE (r = 0.45, p < 0.001).
Optimal test sensitivity for the
differential diagnosis of dementia/not dementia in this cohort was
found to be 0.39 at the Poppel reuter cutoff of 3/4, and optimal
test specificity was 1.00 at the cutoff of 2/4, with similar test accuracy at both cutoffs (0.72, 0.77
respectively). Traditional parameters of test diagnostic utility at the
3/4, cutoff are shown in Table 2
(right-hand column). Of particular
note, the utility indices indicated
that the Poppelreuter figure was
more useful for ruling out a diagnosis of dementia (good negative

Progress in Neurology and Psychiatry

utility index) than for ruling it in

(very poor positive utility index).
Discussion
The Poppelreuter figure proved
easy to use in clinical practice and
acceptable to patients. This may
relate in part to the relatively low
percentage of dementia patients
seen in the prospective cohort (28
per cent), half that in the retrospective cohort (albeit not consecutive patients), a trend recently
observed in this clinic and possibly related to the recommendations of the National Dementia
Strategy prompting referral of
more worried well memory complainers.23
Although considered a multicomponential task by some
authors, the visuospatial components of the Poppelreuter figure
are clearly the most important.18
It was therefore not surprising that
the Poppelreuter results were correlated with other tests of visual
perceptual function, particularly
the fragmented letters test, which
requires figure/ground discrimination, in comparison to general
screening tests such as MMSE and
ACE, hence showing concurrent
validity. The reason(s) for the difference in Poppelreuter correlation with the visuoconstructional
intersecting pentagons task
between the two cohorts is uncertain, but may possibly be related to
case mix.
The Poppelreuter figure
proved very specific but not very
sensitive for a diagnosis of dementia in both cohorts, and the overall
diagnostic accuracy as measured
by the ROC curve was suboptimal
(> 0.75 is usually considered desirable for a diagnostic test), particularly when compared to some
general screening tests such as the
ACE-R,24 but on a par with scales
such as the PHQ-9. 25 However,
like the PHQ-9, the Poppelreuter
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Poppelreuter figure

Key points
Visual perceptual function may be impaired in cognitive disorders,
including Alzheimers disease
Many of the standard cognitive screening instruments include little or
no testing of visual perceptual function
The Poppelreuter figure of four overlapping images is a simple test of
visual perceptual function, easily applicable in the clinic and acceptable
to patients
In both retrospective and prospective studies in cognitive clinic patients,
the Poppelreuter figure had a high specificity for the diagnosis of
dementia, scores above a cutoff of 3/4 ruling out a diagnosis of
dementia

figure has pragmatic value: the

good negative utility index indicates that it is useful for ruling out
a diagnosis of dementia, rather
than for ruling it in (poor positive
utility index). A possible exception to this rule may be cases of
posterior cortical atrophy (visual
variant Alzheimers disease): all
the cases in these studies performed below the cutoff 3/4.
Although numbers of cases
were too small to permit examination of test performance with stage
of dementia, the low sensitivity
result suggests the Poppelreuter
figure would not be a useful screen
for early identification of dementia, but poor performance is a reliable indicator that dementia has
set in.
Nonetheless, because of the
good negative utility index, the
Poppelreuter figure is useful for
ruling out a diagnosis of dementia. The Poppelreuter figure
might therefore be useful as a
visual perceptual task in a general
dementia screening test or as one
component of a broader assessment battery. It might also prove
to be a useful and quick standalone screen for dementia, perhaps readily applicable in primary
care where time available for testing is brief.
Rebecca Sells is a final year medical
student and Dr Larner is a
www.progressnp.com

Consultant Neurologist, Cognitive

Function Clinic, Walton Centre for
Neurology and Neurosurgery,
Liverpool
Declaration of interests
None declared.
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