A cognitive test is an assessment of a person’s ability to think and remember, but what exactly does it consist of? Is there just one cognitive function test? What are the specific cognitive abilities that are assessed? How do experts interpret the results?

At the Doctor’s Office

When a person begins to experience increasingly frequent memory lapses, he or she will often approach their doctor with their concerns. Some measure of short-term memory loss is to be expected for people past age 50, but if someone has more severe deficits than others their age, they may be suffering from mild cognitive impairment (MCI). MCI is a specific term referring to people who fit that description but whose cognitive issues do not interfere significantly with the activities of daily life. Cognitive testing plays an important role in diagnosing MCI.

Primary care doctors may perform simple tests of memory and cognition during an office visit in which concerns are raised or impairment is suspected. Rather than yielding definitive results and diagnoses, these are more like screening tools to identify people who should undergo more in-depth evaluation by specialists.

The two most common tools are:

  • The Mini-Mental State Examination (MMSE). Rather than simply testing memory, the MMSE, which was created in 1975 and takes less than 10 minutes, assesses various aspects of a person’s cognition, including their ability to orient themselves in space and time, perform mental calculations, follow spatial patterns, remember words spoken, identify objects, and follow simple commands. For example, people undergoing the MMSE are asked to identify the day, month, season and year, as well as to name the state, county, hospital, and floor in which examination is taking place. They’ll be asked to count backward from 100 by sevens, to identify by names simple objects such as pencils and wristwatches, to write a simple sentence, to copy a basic geometrical drawing, and to perform other similar tasks. Scoring is done on a scale from zero to 30, with anything lower than 26 indicating a likelihood of MCI.
  • The Montreal Cognitive Assessment (MoCA). This test, created in 2005 to build on the MMSE, takes only a few minutes more than the MMSE to administer. Through 11 tasks, it measures seven areas of cognition including attention, abstraction, and executive function, and is graded on a scale going up to 30 possible points. When taking the MoCA, for example, the person is asked to trace a sequence on a paper following the pattern 1->A->2-B etcetera up to 5->E. Next, he or she must copy a simple stick-figure drawing, draw a clock face showing a specific time, identify drawings of common animals, repeat a list of unrelated words, spend a minute naming as many words as possible beginning with a specific letter of the alphabet, repeat two sentences of moderate complexity, and categorize sets of common objects. As with the MMSE, the person also must identify the place and time and count backward from 100 by sevens. A score of 25 or less indicates possible MCI. (Since some of the questions are more challenging for people with little schooling, one point is added to the score if the person has completed 12 or fewer years of education).

The MMSE is generally thought to be better at identifying more severe forms of cognitive impairment, while the MoCA outperforms when it comes to detecting MCI. The MMSE is only able to correctly identify 18% of test-takers who have MCI, while the MoCA correctly identifies 90% of cases. Conversely, the MMSE correctly identifies 100% of people who do not have MCI, compared to 87% with the MoCA.

The MoCA is currently the most widely used in-office screening tool for MCI. Recent years have seen the creation of alternatives, but none have gained enough traction to unseat the MoCA. These include the Saint Louis University Mental Status (SLUMS) exam and the Short Portable Mental Status Questionnaire (SPMSQ).

What Comes After the Test Results

If the administrator of the MMSE or MoCA determines that a person’s score suggests cognitive impairment, they will likely refer that person to a neuropsychologist for a much more intensive battery of assessments. Rather than just taking a few minutes as with the MMSE or MoCA, the neuropsychologist’s testing can require several hours. It can include:

  • An interview about the person’s life
  • A discussion of their concerns regarding their cognition
  • Examinations performed with pencil and paper
  • Tests done using a computer, keyboard, and mouse

These tests are designed to cover many more aspects of cognition than the screening tests. For example, neuropsychological testing may assess not just attention, language, reasoning, and memory, but organization, problem-solving, judgment, learning, and processing speed, as well as areas adjacent to cognition such as social and fine motor skills.

When the testing is complete, the neuropsychologist scores the person’s performance using standardized scales that compare them to peers of similar age and education level. The neuropsychologist does not make a diagnosis. Instead, he or she writes up a report summarizing the person’s cognitive strengths and weaknesses, any surprising findings, and a series of recommendations for improving on areas of weakness revealed by the testing. The report then goes to your doctors who use the information along with other information available to them to make a diagnosis.

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