A cognitive function test measures brain functions such as memory, attention, language, executive function, and visuospatial skills to detect and track cognitive impairment. Most are screening tools rather than standalone diagnoses. When a patient shows signs of cognitive impairment, time is of the essence. As cognitive deficit can manifest as one of the early symptoms of neurological disorders, cognitive function tests can be crucial for early detection, suitable treatment courses, and better patient outcomes.
Physicians today may find themselves awash in a sea of many different cognitive function tests, including options that rely on subjective measures, involve prohibitive wait times, or do not catch early signs of cognitive deficit. In general, traditional assessment options are either too simple or too long, and there is a gap between where better assessments can fit in.
Read on to learn about the best way to improve patient care with cognitive testing, the strengths and shortcomings of various established cognitive function measures, and the best tests that can close the gap in gaining objective data.
Article Highlights
- Cognitive function tests range from 5 minute paper screeners to full neuropsychological evaluations taking 4 to 8 hours.
- Subjective cognitive decline affects an estimated 11.7% of adults over 65 and 10.8% of adults aged 45 to 64.
- Over 43% of Parkinson's patients eligible for a dementia diagnosis deny functional impairment, and 93% of people with moderate to severe dementia overestimate their own cognitive performance.
- Adults wait 5 to 10 months for a full neuropsychological evaluation and children up to 12 months, at costs often between $1,500 and $4,500.
Why and when should you test cognition?
Reasons for testing cognition can range from self-reported cognitive deficit, memory issues, suspected brain injury, neurological symptoms, and beyond. Here are just a few good reasons you are likely already testing for cognitive function.
Self-reported cognitive concerns. Subjective cognitive decline (SCD) is a self-reported early warning signal for certain cognitive disorders, including Alzheimer's disease and related dementias. SCD has an estimated prevalence of 11.7% among adults over 65 and 10.8% among adults aged 45 to 64, according to CDC surveillance data, keeping demand high for screening among older adults.
As part of a widespread approach to preventative care. Not all symptoms of cognitive deficit are limited to older patients. Even in adults under 45, mild cognitive impairment (MCI) can be an early warning sign of a number of neurological, endocrine, or circulatory conditions. In adults of any age, and even in children, cognitive deficit can also be an early sign of neurodegenerative conditions.
Certain demographics may also be more susceptible to cognitive decline. Black Americans over 70 are twice as likely to develop Alzheimer's or dementia as White Americans, according to Alzheimer's Association data, and Black Americans also face barriers to comprehensive care. Routine screening could form one component of a plan to address patient care deficits among marginalized demographics.
Suspected brain injury. Brain function testing is an essential screening tool in the treatment of traumatic brain injury (TBI), including concussion.
In brief, cognitive tests may be appropriate for patients of all ages and from any background. Even if testing reflects normal levels of cognition, cognitive tests offer improved patient care in the form of peace of mind.
Read more: Three Ways Routine Cognition Assessments Will Improve Your Healthcare Practice
What are the main types of cognitive function tests?
Different cognitive function tests often offer clinicians different levels of information. The table below compares the four most common options, and the sections that follow break down how each is administered, how accessible it is to clinicians, and where its strengths and limitations lie.
| Test | Format | Time | Strongest for | Limitation |
|---|---|---|---|---|
| MMSE | Pencil and paper | 5 to 10 minutes | Moderate to advanced dementia | Misses MCI and is easy to memorize |
| MoCA | Paper, digital, or oral | 10 to 15 minutes | Screening for early cognitive decline | Low sensitivity and risk of misclassification |
| SLUMS | Pencil and paper | About 10 minutes | Logical memory and extrapolation skills | Coarse results and adults 18+ only |
| Neuropsychological evaluation | Specialist administered | 4 to 8 hours | Identifying the nature of an impairment | Cost, wait times, and patient stress |
The Mini Mental State Exam (MMSE)
The Mini Mental State Exam (MMSE) is a test usually administered by pencil and paper, used to assess advanced deficits in cognitive functioning. Testing cognitive skills such as orientation, concentration, attention, verbal memory, language, naming, and visuospatial skills, the MMSE is a common screening tool for moderate to advanced dementia.
The MMSE offers a bird's-eye view of a patient's baseline brain functions. Pros of the MMSE include:
- Ease of access. The MMSE can be given in 5 to 10 minutes during a regular appointment by specialists and general providers alike.
Cons of the MMSE include:
- Easy to memorize. The contents of the MMSE are freely available online. Many of its components are easy to remember.
- Low detection of early cognitive disruption. The MMSE is very good at catching advanced cognitive decline, but unlikely to catch MCI.
The Montreal Cognitive Assessment (MoCA)
The Montreal Cognitive Assessment (MoCA) is a screening method for early cognitive decline and mild cognitive impairment. This test, administered in 10 to 15 minutes, includes simple questions about spatial awareness, naming, short-term memory, language, executive function, attention, and more.
Pros of the MoCA include:
- Adaptability. The MoCA test can be adapted for paper-based, digital, or oral delivery. It also offers accessibility options for patients with low or no vision, and patients who are deaf, hard of hearing, or experiencing hearing loss.
Cons of the MoCA include:
- Impractical. In-person testing is not always practical for a patient, especially in cases when routine assessments would be beneficial.
- Lacks sensitivity. For the MoCA to pick up indicators of cognitive decline, a patient needs to be fairly progressed in their condition. Unfortunately, at this point, intervention is difficult or not possible.
- Generalization of results. The sensitivity and quick administration of this test means that patients with depression, lower levels of literacy, or other obstacles to rapid response may be erroneously classified as cognitively impaired.
SLUMS
The Saint Louis University Mental Status (SLUMS) exam screens for mild cognitive impairment and can help diagnose dementia. Measuring attention, delayed and immediate recall, calculation, executive function, visuospatial response, and more, the SLUMS test is administered by pen and paper and takes approximately 10 minutes to complete.
Pros of the SLUMS test include:
- Measure of logical memory. Unlike the MoCA and MMSE, the SLUMS exam includes testing for memory and extrapolation skills.
- Quick to administer. Taking only 10 minutes, SLUMS provides quick results that a physician can discuss with their patients.
Cons of the SLUMS test include:
- Not recommended for children. SLUMS test guidelines suggest applying the test only to patients aged 18+.
- Lacks sensitivity. Similar to the MoCA, SLUMS uses a definition of MCI that is still quite progressed. This makes treatment and intervention challenging.
- Generalization of results. SLUMS provides a fairly simple set of results, making it difficult to get a holistic and nuanced understanding of the patient's condition.
Neuropsychological testing
Neuropsychological testing is a form of in-depth assessment performed by neuropsychologists or psychologists trained in neuropsychological testing. These full cognitive evaluations generally require appointment-based referrals and can take anywhere from 4 to 8 hours.
Pros of neuropsychological testing include:
- Thoroughness. Unlike pencil-and-paper exams, which may not catch nuances in cognitive ability, a complete evaluation is intended to leave no ambiguity as to whether a cognitive impairment is present, or what its level of severity is.
- Clearer path to diagnosis and treatment. While the above tests measure whether a cognitive impairment is present, a complete evaluation is intended to identify the nature of the cognitive impairment.
Cons of neuropsychological testing include:
- Expense. Due to the involvement of specialists and the amount of time the evaluation takes, expense is a major barrier to a complete neuropsych evaluation.
- Long wait times. Referral times for neuropsychiatric specialists can range from weeks to months. This is a strong disadvantage in a field where early detection can be crucial.
- Stress. The combination of months-long wait times for referrals, the hours-long testing time, plus other elements of travel to the clinic can make for a stressful patient experience.
Four challenges in testing cognitive function
Many cognitive testing options offer either quick, cursory information or time-consuming comprehensive data. Few assessments offer quick but nuanced information. So it can be frustrating to understand how best to evaluate complex patient situations.
Here are four central challenges providers may face in navigating the all-or-nothing nature of cognitive evaluation.
Gaps in objective data collection
Physicians often rely on subjective measures when it comes to deciding on cognitive evaluation. Cognitive changes can be self-reported by patients, or reported by loved ones. Patients may also downplay or deny changes in cognition, even while reporting what people around them have noticed.
Over 43% of Parkinson's patients eligible for a dementia diagnosis deny any functional impairment, according to Parkinson's disease research, and 93% of people with moderate to severe dementia overestimate their performance on cognitive measures, according to dementia self-awareness research.
Though cognitive tests exist to collect the cognition data required for diagnosis and treatment, a comprehensive cognitive test can be a lengthy and expensive process. And while quick pencil-and-paper tests are intended to bridge the evaluation gap, some screening methods can only catch severe impairment.
This creates a Catch-22 scenario: cognitive testing is required to collect cognition data, but tests are sometimes not sensitive enough to catch gradations of impairment.
This issue has particular impact with patients whose cognitive disruption is symptomatic of complex neurological conditions such as Parkinson's disease, multiple sclerosis, or epilepsy. For these patients, a need exists for an "in-between" test, something capable of capturing diverse manifestations of cognitive disruption, to fill gaps in cognition data.
Barriers to access
Though ideally, a full neuropsychological evaluation would be available to anyone who needs it, in reality this type of comprehensive testing has barriers to access. Adults often wait anywhere between 5 to 10 months for a complete evaluation, according to adult wait time research, and children often wait up to 12 months, according to pediatric wait time research.
Cost is also a major prohibitive factor, with MRIs costing between $500 and $4,000 and neuropsych evaluations ranging greatly between states, but often ranging between $1,500 and $4,500 based on published clinic fee schedules and comparable clinic pricing.
The level of literacy and cultural competence required to successfully complete these exams, as well as the time commitment involved, also creates barriers to access. As such, neuropsychological evaluations and brain imaging are not the best starting point for a routine cognitive test.
Inefficient workflows
The question of appropriateness of a particular test for a particular patient also extends to workflow practicality. Given the necessity of in-person evaluation for pencil-and-paper tests, clinicians have to take into account whether in-office consults are possible for all patients, or whether a clinician's office is the right environment to obtain an accurate result.
Physicians spend an average of 15.5 hours per week on paperwork and administration, according to the Medscape compensation report.
Other workflow considerations include whether a complete neuropsych evaluation involves too long of a wait in a field where early intervention may be of the essence, or whether there are other barriers, like cost, to these evaluations for certain patients.
Disorganized recordkeeping
One problem with pencil-and-paper tests is that, well, they are pencil-and-paper. In an increasingly digital world, a physical piece of paper may become a stray artifact when it comes to patient recordkeeping.
Paper can be digitized, but the extra step could mean the paper gets lost or forgotten in the shuffle, or it can take time away from other clinical or administrative activities or seeing other patients. A few minutes to scan and upload a file adds up when seeing dozens of patients a day. Losing that test could create a gap in cognition data and cost more precious treatment time. Physical paper may also make it difficult to communicate test findings when making referrals.
How do you choose the best cognitive function test?
No matter which cognitive function test is used, cognitive testing aims to supply patients with the best possible care. To bridge existing gaps in patient cognitive care planning, no matter the testing approach, consider the following six approaches.
Administer cognitive function tests digitally
When cognitive function tests can be completed digitally, it provides clinicians with ease of insight into changes in a patient's cognitive processes. Longitudinal data can be automatically included in a single report, rather than manually comparing separate reports. Plus, comparisons against normative patient data, built directly into the report, can be especially useful in assessing mild to moderate cognitive impairment.
Test in office or at home
It can be important to see your patients' brain functioning in real time, but flexibility can also be crucial for patients with barriers to in-office appointments. At-home testing eliminates the effect of appointment anxiety, or forgetting appointments altogether, and allows them to be assessed in their most comfortable environment: their own.
Prioritize quick cognitive testing
A full neuropsychological evaluation can take hours, which can be time consuming, prohibitive, or exhausting for patients. Tests that objectively measure cognition and can be completed in 15 minutes can give you detailed insight into a patient's cognitive functions in the span of a coffee break.
By prioritizing a quick test that also offers validated results, it can be a more accurate indicator for whether further testing is necessary. This leads to a better patient experience that is mindful of their time and expense.
Seek detailed testing results
Prioritize testing that is as quick as possible, but does not compromise nuance and detail. Unless all signs point to advanced dementia, a bird's-eye view of your patient's cognitive ability usually will not be detailed enough to drive diagnosis and treatment. A complex, graded results scale equips both clinicians and patients with information for the care they need.
Use cognitive tasks with multiple versions
When tests are not memorizable, they ensure more accurate reflections of a patient's true cognitive function. Evaluations that test the same skills but in different patterns are particularly useful for comparison of cognitive performance over time. Digital tasks have the advantage of introducing randomization for essentially unlimited versions of each task.
Apply cognitive testing backed by science
Some "personality tests" found easily online will claim to test cognitive function. But patients seeking the support of their healthcare provider want answers they can trust. Be sure that your cognitive function tests are specially based in real neuroscience for useful results.
How the Creyos platform closes the testing gap
These cognitive testing challenges do not need to be the status quo. The Creyos platform quantifies subtle impairment and is accessible, efficient, digital, and backed by science.
With the reimbursable Creyos platform, you can:
- Complement subjective assessments with data. Compare and rank patient performance against others in their age group using the Creyos normative database, featuring more than 85,000 individual scores.
- Test patient performance in-office or at home. Flexibility can help meet complex patient needs and increase the efficiency of provider workflows.
- Customize test parameters. Add practice rounds, adjust or remove sound, and include tutorials to give patients an assessment tailored to their needs.
- Gain fast, frequent patient insights. With integrated workflows, track changes in a patient's cognitive processes easily by scheduling regular testing, without the hassle of booking an appointment. Plus, digital records keep patient information organized and integrate with your EMR.
Improving patient care can be as simple as offering patients a customizable test that can be administered anywhere, anytime. Book a demo to learn about the full benefits of the Creyos platform.
Overcoming the limits of cognitive testing
No matter which cognitive testing method is used, closing gaps in patient care becomes more important than ever as the aging population grows.
Modern, digital cognitive assessment methods like the Creyos platform can address challenges previously seen in cognitive function testing, such as accessibility, cost in money and time, patient suitability, ease of integrating with clinic workflow, and more. Flexible, science-validated testing that yields detailed results is about more than just effective treatment. It is about taking a proactive approach to improving health care practice.
Whether patients have emerging health concerns, established dysfunction, or just want to keep an eye on their cognitive health, incorporating cognitive function testing as part of routine cognitive health care can improve patient outcomes for years to come.
Reviewed by Sydni Paleczny, Staff Scientist at Creyos
Sydni earned her MSc in Neurosciences at Western University under Dr. Adrian Owen. Her research explores neuropsychological outcomes after cardiac surgery, with interests in cognitive neuroscience, critical care, and brain health. At Creyos, she supports scientific validity, health technology, and ongoing research.