Office based Cognitive Questionnaires

Timothy C. Hain, MD • Page last modified: July 30, 2022Return to testing index

Everything affects everything (this is "holistic" or "systems" thinking), and some dizzy people have problems with thinking. For example, many complain of "brain fog", and sometimes think worse on "their feet" than sitting down. In addition, modern medicine emphasizes measurements that can be converted into numbers and reported to the government or insurance companies, producing an industry based on asking people questions and recording their answers into electronic medical records.

Curiously enough, the US preventative services task force (2020) did NOT recommend doing these tests -- instead, they concluded " the current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment in older adults. " Our position on this although evidence is insufficient, in general, it is better to collect this data.

Here we briefly review the commonly used office based tests of cognition.

Office based cognitive tests
Time 7-10 10-13 10 10-15
Cost in $ about 2$ Free for paper Free Free for paper
Cost in paper 1 page 1 page 1 page 4 pages+disclaimer
Advantages Well known Less ceiling effect Less ceiling effect, emphasizes memory Less ceiling effect
Disadvantages Ceiling effect Takes a while Less language/executive Little memory


The four tests above were reviewed in Practical Neurology (2019) as being suitable for detecting dementia. These are all sets of questions, usually developed with public funding, often sold by some group.

This seems unethical to us -- If you can sell a particular set of questions -- why not sell air ? Or the Golden Gate bridge ? Maybe you can sell a copyrighted set of questions for 12 years -- but we don't think forever. We are OK with people offering computer versions for sale -- this is a service. We get it that people want to be paid for their work, but we don't think that material developed with government funding, or works written many years ago, should be marketable. We don't think, similarly, that readers of other literary works, such as Emily Dickenson's poems should be charged 2 $ a read (as is suggested for MMSE). One also wonders in a distruptive way -- why not mix/match ? Replace a few questions from the MMSE, SLUMS or SAGE with similar questions from the Moca or whatever -- then copyright that. The possibilities are almost endless.

Well anyway, basically the MMSE is the "old timer" in this group, the MoCA is the "new standard" , and SLUMS/SAGE are wannabe tests. These tests are not reimbursable by insurance (unlike tests of anxiety which are -- strange eh ?)

There are numerous studies that suggest that Moca is superior to MMSE (e.g. Alagiakrishnan et al, 2013, Sikaroodi et al, 2013). The SLUMS also seems a little better than the MMSE (Feliciano et al, 2013). The long SAGE performs better than than the MMSE, but 4 pages is too much. We also think the name is quite a stretch -- "Self-administered Gerocognitive Examination (SAGE)". Gerocognitive ? Who talks like that ? But I guess "Slums" is also a problem.

Regarding implementation, the "free" tests (i.e. all but the MMSE) have an infinate advantage over the MMSE in pricing, and we expect the MMSE will eventually vanish. The very long test (SAGE) is too long compared to the competition. So ultimately it comes down to MoCA vs SLUMS. MoCA seems to be the winner right now.

That being said, the MoCA group seems to be trying to monetize their test as well. I guess there is probably no alternative now to the SLUMS.

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