Cognitive Assessment Training — Banksia Medical Centre

Which tool to use?

Criterion	Mini-Cog	MoCA	MMSE
Time to administer	3–5 minutes	10–15 minutes	10–15 minutes
Best use case	Initial rapid screen — all patients	Mild cognitive impairment detection	Established diagnosis follow-up
MCI sensitivity	Moderate	High — preferred for MCI	Low — misses MCI often
Education bias	Low	Moderate (education adjustment)	High — disadvantages lower education
Recommended order	First — use as entry screen	Second — if Mini-Cog positive/borderline	Third — when MoCA unavailable or for tracking
Training required	Minimal — nurse can administer	Moderate — nurse with GP oversight	Moderate — nurse with GP oversight
Cost	Free	Free (dementia.org.au)	Copyright — fee for commercial use

Mini-Cog — Quick Reference

Time

3–5 minutes

Max score

5 points

Cut-off

≤2 = positive screen

Components

3-word recall + clock draw

Who

Nurse-administered

Education bias

Low

Before You Begin — Preparation

Set up the environment

Ensure a quiet room with minimal distractions. Sit at eye level with the patient. Have blank paper and a pen ready. Do not use pre-printed clock forms for the Mini-Cog.

Explain the purpose

Say: "I'm going to ask you to do a few brief memory tasks. There are no right or wrong answers — I just want to get a sense of how your memory is working today."

💬 Use a calm, reassuring tone. Normalise the assessment — many patients feel anxious about memory tests.

Check hearing and vision

Confirm the patient can hear your instructions clearly and can see the paper. If hearing aids or glasses are needed, ensure they are in place before beginning.

Step 1 — Three-Word Registration

Give the instruction

Say: "I am going to say three words. I want you to remember them because I will ask you to repeat them in a few minutes. The words are: BANANA — SUNRISE — CHAIR."

⚠ Say the words clearly, one at a time, at a normal pace. Do NOT write the words down or show them to the patient.

Confirm registration

Ask the patient to repeat the three words back immediately. If they cannot recall all three after two attempts, proceed but note this. Do not score this step — it is only to confirm the words were registered.

ℹ Any three unrelated words can be used (e.g. LEADER – SEASON – TABLE). Use the same three words consistently within your practice for standardisation.

Step 2 — Clock Drawing Test (CDT)

Give the paper and instruction

Hand the patient a blank piece of paper. Say: "Please draw a clock. Put all the numbers on it and set the time to ten past eleven."

💡 "Ten past eleven" (11:10) is the standard time — hands point to both sides of the clock, testing spatial distribution of numbers.

Do not assist

Allow the patient to complete the clock independently. Do not prompt, correct, or indicate whether they are doing it correctly. Note the time taken.

Score the clock — Normal (2 points)

A normal clock requires ALL of the following:

All 12 numbers present and in correct sequence

Numbers placed in correct spatial position (roughly circular)

Two hands present

Hands indicate 11:10 (hour hand near 11, minute hand near 2)

Score the clock — Abnormal (0 points)

Score 0 if any of the following are present:

Missing or incorrect numbers

Numbers outside the clock face or in wrong positions

Missing hands or hands not indicating correct time

Clock face not roughly circular

⚠ When in doubt, score 0. The clock is a binary score — 2 or 0 only.

Step 3 — Three-Word Recall

Ask for word recall

Say: "What were the three words I asked you to remember?" Allow up to 60 seconds. Do not prompt or give clues.

Score the recall

Award 1 point for each word recalled correctly (maximum 3 points). Spelling errors are acceptable if clearly the correct word. Order does not matter.

Scoring & Interpretation

Score calculation

Word recall: 1 point per word recalled (0–3 points)

Clock drawing: Normal = 2 points, Abnormal = 0 points

Total: 0–5 points

3–5

Negative screen

Low likelihood of dementia — monitor at routine intervals

0–2

Positive screen

Further assessment required — proceed to MoCA or GP review

✓ Score 3–5: Actions

Document result in PMS with date
Reassure patient — low likelihood of significant cognitive impairment
Schedule routine re-screen as clinically appropriate (typically 12 months)
Address any modifiable risk factors identified

⚠ Score 0–2: Actions

Do NOT diagnose dementia based on Mini-Cog alone
Proceed to MoCA for comprehensive assessment
Flag for GP review and clinical correlation
Document in PMS and notify GP same day
Consider caregiver interview if available

MoCA — Quick Reference

Time

10–15 minutes

Max score

30 points (+1 education)

Cut-off

≤25 = possible MCI

Domains

8 cognitive domains

Who

Nurse with GP oversight

Download

mocatest.org

Before You Begin — Preparation

Download and print the MoCA form

The official MoCA form is available free at mocatest.org. Print one copy per patient on plain white paper. The form includes all required stimuli (trail, cube, clock face, word list, sentence, etc.).

ℹ The MoCA Basic version is available for patients with limited literacy or education. Use the standard version for all other patients.

Record education level

Before starting, confirm: "How many years of formal schooling did you complete?" If 12 years or fewer, add 1 point to the final score (education adjustment).

Introduce the test

Say: "I am going to ask you to do several different tasks. Some may seem easy and some more difficult. Please try your best on each one."

⚠ Do not tell the patient their score during the test or between subtests. Remain neutral throughout.

Domain-by-Domain Administration

Domain	Points	Administration	Scoring
Visuospatial / Executive Trail, cube, clock	5	Trail B (1pt): connect alternating numbers and letters. Cube copy (1pt): copy 3D cube. Clock (3pts): draw face, numbers, hands at 10 past 11.	Trail: correct sequence, no errors. Cube: 3D shape roughly preserved. Clock: contour (1), numbers (1), hands (1).
Naming 3 animals	3	Show pictures of lion, rhinoceros, camel. Ask: "What animal is this?"	1 point each for: lion (or lioness), rhinoceros (or rhino), camel (or dromedary).
Memory 5-word recall (delayed)	5	Read 5 words at 1 per second: FACE – VELVET – CHURCH – DAISY – RED. Ask patient to repeat them. Read again. Recall tested later after 5 minutes.	1 point per word recalled without cue after the delay. No points for cued recall (scoring only counts free recall).
Attention Digit span, vigilance, serial 7s	6	Forward digits (5-2-1-4-2-3): repeat in order (1pt). Backward digits (7-4-2): repeat in reverse (1pt). Tap on letter A in sequence (1pt). Serial 7s from 100: 93–86–79–72–65 (3pts).	Digit spans: exact sequence only. Vigilance: ≤1 error = 1pt. Serial 7s: 3pts for 4–5 correct; 2pts for 2–3 correct; 1pt for 1 correct; 0 for none.
Language Sentence repeat, fluency	3	Repeat: "I only know that John is the one to help today." Then: "The cat always hid under the couch when dogs were in the room." (2pts). List maximum words beginning with F in 60 seconds (1pt).	Sentences: 1pt each, exact repetition only. Fluency: ≥11 words = 1pt.
Abstraction Similarity pairs	2	Ask: "In what way are a train and a bicycle alike?" (example, not scored). Then: "In what way are a watch and a ruler alike?" and "In what way are a carrot and a cauliflower alike?"	Accept: measuring instruments / tools of measurement (watch/ruler). Accept: vegetables / food (carrot/cauliflower). Do NOT accept less abstract answers (e.g. "they both have numbers").
Delayed Recall 5-word free recall	5	After at least 5 minutes have passed (during other subtests), ask: "Earlier I read a list of words. Tell me as many as you can remember."	1pt per word recalled without cue. Optional: offer category cue then multiple choice cue — record but do not add to score.
Orientation Date, place	6	Ask: date, month, year, day of week, place, city/town.	1pt each for: date (±2 days accepted), month, year, day, place (building/location), city. Do not prompt.

Scoring & Interpretation

Score calculation

Sum all domain scores (maximum 30 points)

Education adjustment: Add 1 point if ≤12 years formal education

Maximum total: 30 points

26–30

Normal

No significant cognitive impairment detected

18–25

Mild impairment

Possible MCI — GP review and clinical correlation required

10–17

Moderate impairment

Likely dementia — specialist referral recommended

0–9

Severe impairment

Severe dementia — urgent GP review and specialist referral

✓ Score 26–30: Actions

Document result in PMS
Address modifiable risk factors
Routine monitoring — re-screen in 12 months or if concerns arise

⚠ Score 18–25: Actions

Flag for GP review — do not diagnose MCI based on MoCA alone
GP to complete clinical assessment and history
Consider referral to geriatrician or neuropsychologist
Initiate care plan — medication review, falls risk, driving assessment if relevant
Engage caregiver/family with patient consent
Re-screen in 6 months

⚠ Score <18: Actions

GP review required — likely dementia diagnosis pathway
Specialist referral (geriatrician / neurologist)
Initiate comprehensive care plan
ACAT referral if community support needed
Advanced care planning discussion
Notify caregiver with patient consent

MMSE — Quick Reference

Time

10–15 minutes

Max score

30 points

Cut-off

≤23 = possible impairment

Domains

Orientation, memory, language

Note

Best for

Longitudinal tracking

Important Notes Before Use

The MMSE is owned by PAR (Psychological Assessment Resources). Commercial use requires a license and fee. For use within the BCCI program, use MoCA (free) as the primary tool. MMSE is included here for reference where it is already in use or where MoCA is unavailable.

⚠ Do not photocopy or reproduce the MMSE form without a valid license. Purchase official forms from PAR at parinc.com.

Limitations

The MMSE has low sensitivity for mild cognitive impairment and is biased against patients with lower education and non-English backgrounds. It does not assess executive function. MoCA is preferred for MCI detection within this program.

Domain-by-Domain Administration

Domain	Points	Administration & Scoring
Orientation to Time	5	Ask: year, season, date, day of week, month. 1 point each. No partial credit. Season: accept adjacent season within 2 weeks of change.
Orientation to Place	5	Ask: country, state/territory, town/city, location (hospital/clinic/home), floor/room number. 1 point each.
Registration	3	Name 3 unrelated objects clearly (e.g. APPLE – TABLE – PENNY). Ask patient to repeat. Score number correct on first attempt (0–3). Repeat up to 6 times until all 3 learned.
Attention & Calculation	5	Serial 7s: subtract 7 from 100, keep subtracting (93–86–79–72–65). 1pt per correct subtraction (5 total). Alternatively: spell WORLD backwards (D-L-R-O-W). Use whichever gives higher score.
Recall	3	Ask patient to recall the 3 objects registered earlier. 1 point each. No cues.
Naming	2	Show a watch: "What is this?" (1pt). Show a pencil: "What is this?" (1pt).
Repetition	1	Say: "Repeat after me: No ifs, ands, or buts." One attempt only. Exact repetition required (1pt).
3-Stage Command	3	Hand patient a piece of paper. Say: "Take the paper in your right hand, fold it in half, and put it on the floor." 1pt per stage completed correctly.
Reading	1	Show written instruction: "CLOSE YOUR EYES". Patient must read and perform the action (1pt). Not scored if patient cannot read.
Writing	1	Ask patient to write a complete sentence. Must have subject and verb and make sense (1pt). Grammar and spelling errors ignored.
Visuospatial	1	Ask patient to copy intersecting pentagons. Both pentagons must have 5 sides, and the intersection must form a 4-sided figure (1pt). Tremor and rotation ignored.

Scoring & Interpretation

24–30

No impairment

Normal cognitive function — monitor routinely

18–23

Mild impairment

Possible MCI or early dementia — GP review

10–17

Moderate impairment

Likely dementia — specialist referral

0–9

Severe impairment

Severe dementia — urgent review

⚠ Education adjustment: Reduce cut-off by 2–3 points for patients with less than 8 years of formal education. Increase suspicion for impairment in highly educated patients with scores in the 24–26 range.

MMSE vs MoCA — Key Difference

MMSE misses up to 80% of MCI cases — a normal MMSE does not rule out MCI
If MMSE is normal but clinical concern persists, proceed to MoCA
MMSE is more useful for tracking known dementia over time than for initial detection
Within the BCCI program: use Mini-Cog first, then MoCA. Use MMSE only where MoCA is not available.

Cognitive AssessmentTool Guide

Cognitive Assessment
Tool Guide