Brief cognitive tests for clinical practice

Overview

The increasing prevalence of cognitive disorders among the aging population calls for more frequent assessments of memory and other cognitive functions for many good reasons. Cognitive deficits, especially mild ones, often cannot be detected in standard clinical interviews. Therefore, it is essential in clinical practice to use any available brief cognitive test by general practitioners and physicians of other disciplines to enable early detection –⁠ preferably at the stage of mild cognitive impairment. This is a crucial step toward timely diagnosis and initiation of appropriate treatment, including emerging biological interventions with monoclonal antibodies, which may significantly slow disease progression and improve the quality of life for both patients and their caregivers. The purpose of this review is to present a selection of options based on interdisciplinary recommendations from which to choose. These include the Amnesia Light and Brief Assessment (ALBA) and the Picture Naming and Immediate Recall Test (PICNIR), both of which are certified tools by the Ministry of Health of the Czech Republic. The article also describes the characteristics of Czech versions of foreign tests, such as the Animal Fluency Test, the Addenbrooke’s Cognitive Examination (ACE-III), the Montreal Cognitive Assessment (MoCA), the Clock Drawing Test (CDT), the Mini-Cog, and the Mini-Mental State Examination (MMSE). All validated tests in the Czech Republic are also well applicable for Slovak colleagues due to the close linguistic and cultural similarity. From 2025 onwards, any of the listed tests may be used to demonstrate cognitive impairment for the prescription of cognitive enhancers, as the exclusive reliance on the MMSE has been discontinued. We provide an overview of the indications for cognitive enhancers based on both certified tests, ALBA and PICNIR. The tests are categorized by their ability to detect mild cognitive impairment or dementia and by administration time. This article aims to raise awareness of brief cognitive tests and promote their broader use, particularly in older adults.

Keywords:

dementia – Mini-Cog – Montreal Cognitive Assessment (MoCA) – cognitive test – Amnesia Light and Brief Assessment (ALBA) – Picture Naming and Recall Test (POBAV) – Mini-Mental State Examination (MMSE) – Addenbrooke’s Cognitive Examination (ACE) – animal fluency test – Clock Drawing Test (CDT) – mild cognitive impairment (MCI)

This is an unauthorised machine translation into English made using the DeepL Translate Pro translator. The editors do not guarantee that the content of the article corresponds fully to the original language version.

Introduction

With an aging population, cognitive disorders are becoming increasingly common. Mild cognitive impairment (MCI) and dementia are increasingly recognized as a global public health problem. Dementia syndrome is a decline in cognitive function that affects daily life, while MCI is a milder form of impairment that does not interfere with independence [1,2]. Early identification of memory disorders is crucial for initiating adequate therapy, which can slow the progression of the disease and contribute to maintaining the quality of life of patients and their caregivers [3]. Knowledge of cognitive functions, including memory, can be of great importance and have significant implications for diagnosis and therapy for physicians of various specialties (neglected or incorrectly used medication, non-cooperation, etc.). We perform cognitive function tests if the patient or their family complains of memory problems, forgets appointments, does not follow treatment regimens, does not respond appropriately, as part of screening, needs to objectify cognitive impairment for the prescription of cognitive enhancers for Alzheimer's disease (AD), after brain damage, or when the patient has been referred for memory testing by another physician. We use short cognitive tests to detect cognitive impairment (MCP or dementia), to assess its severity, and to monitor its progression [1,4,5]. Depending on their duration, they can be short (up to 5 minutes) or longer, usually 10–30 minutes [6].

Short cognitive tests should be incorporated into regular preventive check-ups for seniors [5,7]. General practitioners play a key role in screening for cognitive impairment, especially in patients in the at-risk age group or in patients with known risk factors for the development and progression of cognitive impairment. Early detection of dementia in a general practitioner's office is a crucial step towards timely diagnosis and initiation of adequate treatment, which can significantly slow the progression of the disease and improve the quality of life of both the patient and their caregivers. It will be necessary to detect patients in the early stages of the disease (MKP) so that they can be offered costly biological treatment for AN. According to the 2024 guidelines, general practitioners should perform routine cognitive function screening as part of a preventive check-up once every two years for people aged 65–80. Although screening is limited to this age group, increased attention must also be paid to older patients, among whom the prevalence of dementia is highest. For people over 80 years of age, active screening for cognitive impairment is recommended in the form of a targeted clinical examination supplemented by an objective medical history from a caregiver or family member [7]. Another reason for cognitive function testing by a general practitioner is a complaint of memory impairment by the patient themselves or their relatives. Statistics for 2023 show an increase in the use of early dementia screening in the Czech Republic, with an average of 15% of people aged 65–80 being screened. In various regions, less than 20% of patients in this age group participated, and in some parts of the country, the figure was even below 10% [8]. Therefore, this article should also contribute to improving the situation.

A high-quality screening test should be sufficiently sensitive, specific, free of charge, easy to administer, and accessible even to patients with mild visual or hearing impairments [9]. The quality of a test or questionnaire is determined by its sensitivity and specificity. The examination of cognitive functions using tests is one of the pillars of dementia diagnosis, especially AD [10]. In this article, we provide an overview of original Czech tests and adaptations of foreign methods used in common practice in the Czech Republic. Their list and psychometric properties are shown in Table 1 [11–25]. The corresponding author draws on his extensive experience, as he has been involved in cognitive testing for a long time. He has developed original Czech tests and has been significantly involved in the transfer of tests from abroad to the Czech environment, as will be apparent from the following text and citations. We describe the recently developed original Czech instruments and their innovations in more detail, as no comprehensive information about them has been published in this neurological journal to date, unlike in journals of other specialties (Medicína pro praxi, Geriatrie a Gerontologie). Czech versions of foreign tests have been published repeatedly in our professional literature. Therefore, we briefly highlight their most important features. This article is primarily intended for physicians of various specialties and others involved in testing patients' memory, such as psychologists, speech therapists, nurses, social workers, occupational therapists, and pharmacists. First, we focus on tests for detecting MCI, followed by tests that can be used in the dementia stage. We then classify them according to duration as very short (up to 5 minutes) and longer.

 

Tests for mild cognitive impairment

Very short tests up to 5 minutes

Amnesia Light and Brief Assessment (ALBA)

Amnesia Light and Brief Assessment (ALBA) is an innovative Czech test designed for the rapid detection of cognitive impairment. It takes only 2–3 minutes, requires no aids, and is also suitable for visually impaired patients [13]. The test consists of two parts. In the sentence test, the patient repeats a six-word sentence and then recalls it after the gesture test. Between repeating and recalling the sentence, there is a gesture test in which the patient first performs six gestures according to instructions and then tries to recall them in any order. A more detailed description of the ALBA test can be found at . A sample record sheet is shown in Fig. 1 and a diagram in Fig. 2. Memory according to the ALBA test is assessed using the ALBA memory score, which is calculated as the sum of the number of correctly recalled gestures and words in the sentence. An individual's memory can therefore be assessed according to this score on a wider scale of 0–12 points (a maximum of six words and six gestures). The threshold score for the ALBA memory score is easy to remember using the mnemonic device of 50% of the maximum. The threshold score of six points applies to people without a high school diploma, while for people with a high school diploma or higher education, the requirements are slightly higher, with a score of at least seven points. The influence of age from the same study is minimal [11]. To further distinguish the severity of the disorder, we can use the mnemonic device of 25% of the maximum borderline score, which is 3 points. Mild impairment is 4–5 points without a high school diploma and 4–6 points with a high school diploma. Severe memory impairment corresponds to the remaining range of 0–3 points. This is clearly shown in Table 2 [11,14,20,26]. The ALBA test is validated for the detection of mild cognitive deficits. Its development and validation have been described in Czech and foreign publications [11,27,28]. Two alternative versions of the test are also available [28]. Thanks to its simplicity and speed, the ALBA test is suitable for examining patients in outpatient clinics, hospitals, and emergency rooms. You can also easily familiarize yourself with the ALBA test on websites and YouTube [29,30].

 

Picture Naming and Equipment Test (POBAV)

The Picture Naming and Equipment Test (POBAV) is an original Czech test for rapid assessment of cognitive functions (semantic and short-term memory). The patient names 20 pictures in writing with one word without time limit and immediately afterwards has to describe as many pictures as possible within one minute [13]. The pictures are black and white, which makes them more cognitively challenging to recognize and name. During development, three versions of the test were created, named after the first pictures (hedgehog, monkey, and the most challenging to name, door) [13,31]. Figure 3 shows a completed and evaluated record sheet for the door version of the POBAV test. The reliability of the parallel hedgehog and monkey forms has been proven, which supports its use for repeated measurement of cognitive functions [32]. The naming of pictures selected for the door version showed high consistency of naming among 5,290 ordinary people in the Czech Republic aged 11–90 with 8–28 years of education [31,33]. The test takes 4–5 minutes to complete and evaluate, with most tasks (written naming, written picture recall) performed independently by the patient and the physician only administering and evaluating the test. While the patient is naming the pictures, the administrator has time to do other things, such as sending a prescription or finishing a medical report. A pre-printed record sheet with pictures and a timer are needed for testing. The results for naming and recalling pictures are evaluated separately. For naming, the number of errors in naming, such as unnamed or incorrectly named pictures, is evaluated. Picture recall is evaluated based on the number of correctly recalled picture names. Individuals should not make any mistakes when naming pictures. We tolerate a maximum of one error. We consider 2-3 errors to be a mild disorder. A severe impairment corresponds to four or more errors. In the picture naming phase, the individual should remember and write down at least one-third of the maximum 20 pictures, i.e., usually between 5 and 8 picture names, depending on age, education, and gender. Further differentiation of the severity of the disorder is the same as in the ALBA test. Mild impairment is between three and the borderline number of picture names. Severe impairment of short-term memory corresponds to 0–2 picture names. There is no ceiling effect of high or maximum scores. The division of scores into normal, mildly and clearly abnormal in the POBAV test is shown in Table 2. Czech standards can be downloaded from the website [29]. During long-term monitoring, we observe a so-called seesaw phenomenon in some patients in the POBAV test, which aptly describes cognitive counter-changes as swinging on a pendulum swing. The number of naming errors gradually increases, and thus semantic memory impairment progresses. At the same time, the number of correctly recalled picture names decreases, and thus short-term memory impairment progresses [34]. The POBAV test shows a high degree of correlation with the Montreal Cognitive Assessment (MoCA), especially in seniors in institutional care. It offers a faster and more practical alternative focused on language and memory skills [35]. The test is particularly useful for rapid screening of memory deficits and for identifying MCI or early stages of dementia [12,36]. At our workplace, the POBAV test is used not only in patients with suspected cognitive impairment, but also in their descendants, often in conjunction with brain SPECT for assessing cerebral perfusion [37]. The POBAV test is also suitable for primary care and emergency admissions [7]. The administration and evaluation of the test can be easily learned on the website and on YouTube [38].

 

Joint use of both certified tests, ALBA and POBAV

The combined use of the ALBA and POBAV tests offers rapid and effective detection of cognitive disorders, particularly MCI, in various clinical situations [34,39]. Both tests, ALBA and POBAV, have been recognized as certified methodologies by the Ministry of Health and are therefore certified tests [40–42]. They focus on information retrieval, which is important for detecting early stages of cognitive impairment [43]. The sensitivities and specificities of both tests for MCI and dementia are shown in Table 1. We recommend using both tests simultaneously if possible, as each measures something different and in a different way, thus providing a more comprehensive view of cognitive function. The combination of the three scores from both tests (ALBA memory score, number of errors in naming pictures, number of correctly recalled picture names) allows us to create ten cognitive profiles that more accurately reflect the nature and severity of the disorders. If all results are within normal limits, it is cognitive profile 1. If there is only one abnormal result out of three, it is profile 2, 3, or 4. Three combinations of two abnormal scores out of three form profiles 5, 6, and 7, which correspond to mild cognitive impairment. Profiles 8–10 describe abnormal results in all three test scores, indicating severe impairment. Details of the cognitive profiles are shown in Table 3. At our workplace, we are investigating the benefits of both the ALBA and POBAV tests in patients after CMP according to comprehensive care recommendations [44]. The ALBA and POBAV tests are used for screening cognitive disorders in certified pharmacies in the Czech Republic [45,46]. Since 2019, 6,323 people interested in memory testing have been examined at BENU pharmacies, with 20% having positive findings and recommendations for further examination by doctors (internal communication). Both tests are one of the examination options for general practitioners [7]. These tests are also reimbursed by some health insurance companies if they are administered by certified clinical speech therapists or pharmacists [47,48]. For the correct performance, evaluation, and interpretation of both tests, record sheets, Czech standards, links to publications, video examples of testing real patients, two online quizzes for users, and links to electronic training courses for each test worth 2 credits from the Czech Medical Chamber on the Medicínské vzdělání educational portal [29,49,50]. The certified ALBA and POBAV tests are the only tests that have this comprehensive support for their use in clinical practice in the Czech Republic. This is not the case with any Czech versions of foreign tests, which may be administered and evaluated by physicians in an inconsistent manner and therefore measure the same cognitive performance differently. The examination with both tests is also simplified by tear-off pads with forms from Schwabe, which can be requested by sending an email to monika.taterova@schwabe.cz.

 

Cognitive indications according to both certified tests, ALBA and POBAV

Starting in 2025, it will be possible to use both certified tests to objectively demonstrate cognitive impairment for the prescription of acetylcholinesterase inhibitors (AChE: donepezil, rivastigmine, galantamine) and memantine, as the requirement to use only the Mini-Mental State Examination (MMSE) test has been abolished. The purpose of using them for this purpose is to start and end cognitive treatment earlier than when using the MMSE. In the Czech Republic, IAChE and memantine are covered by public health insurance only when dementia is diagnosed within the framework of AN. Objective evidence of cognitive impairment and impairment of activities of daily living is required for reimbursement. We use both drug groups gradually, IAChE for mild and moderate dementia, memantine in moderate and severe dementia, and a combination of both is also possible in moderate dementia. The authors believe that it would be appropriate to consider the possibility of initiating this treatment at the MCI stage, when early intervention could help slow the progression of the disease and preserve the patient's functional autonomy. However, health insurance companies do not cover IAChE at this stage due to a lack of evidence. In the case of early detection of MCI caused by AN, the patient can purchase IAChE at their own expense. Paradoxically, in order for health insurance companies to reimburse the cost, it is necessary to wait for progression and loss of self-sufficiency, i.e., the development of dementia.

The previous, now invalid, indication criteria for prescribing IAChE specified numerical thresholds for MMSE scores. If we were to proceed analogously with the results of the ALBA and POBAV tests, we would suggest the following procedure. IAChE drugs are reimbursed for patients with a confirmed diagnosis of dementia in AN with mild to moderate dementia if short-term memory impairment is present in both the ALBA and POBAV tests. Short-term memory impairment is defined as an ALBA test memory score of six points or less (the cut-off score corresponds to 50% of the maximum score of 12 points) and the patient recalling six or fewer picture names in the POBAV test (the borderline score corresponds to one-third of the maximum score of 20 pictures). Table 4 shows the more precise range of ALBA and POBAV test scores, which serve only as a guide and cannot be considered binding criteria. The actual number of points in the test may not correspond to clinical reality, which is influenced by the diversity of cognitive disorders and a number of other factors with a potential impact on the result. The number of errors in naming in the POBAV test is irrelevant for the purposes of prescribing cognitive enhancers. This involves long-term semantic memory and written language, which are unlikely to be affected by IAChE. At the same time, it is necessary to document the patient's lack of self-sufficiency. This can be done in two ways: either through an interview with a caregiver or close relative, which will focus on instrumental activities of daily living, such as the ability to take medication independently, travel, manage finances, use a telephone or appliances, or by using the Functional Status Questionnaire (FAQ) or other validated Czech versions of foreign questionnaires focused on self-sufficiency.

According to the criteria of the health insurance company, the patient's condition must be assessed regularly at intervals of 3-6 months. A comprehensive examination includes repeating the ALBA and POBAV cognitive tests, assessing neuropsychiatric symptoms, and activities of daily living. We discontinue IAChE treatment if follow-up examinations show progression to severe dementia with ALBA and POBAV scores between 0 and 1.

Memantine is covered by health insurance for moderate to severe dementia. In these stages of dementia, the assessment of dependence will be more important than cognitive testing. If we still want to have some guidelines based on the scores of the certified ALBA and POBAV tests, it would be an ALBA memory score of approximately 0–1 points and a POBAV score of 0–1 equipped picture. We discontinue treatment with memantine if follow-up examinations show no effect on neuropsychiatric symptoms, or if dependence or dependence according to the FAQ questionnaire is close to 30 points, i.e., 0%. Table 4 summarizes  the guidelines for prescribing acetylcholinesterase inhibitors and memantine according to the degree of cognitive impairment, ALBA and POBAV scores in accordance with the new health insurance criteria from 2025.

 

Animal verbal production test

The animal word production test is a comprehensive and rapid screening tool focused on assessing semantic word production and capturing MCP [51]. The sensitivity and specificity of the test are shown in Table 1. Patients are asked to name as many animals as possible within a time interval of usually 1 minute. This test allows for the assessment of psychomotor speed, speech and executive abilities, memory, attention, and vocabulary. Impaired semantic verbal production is typical for both MCP and AN. Phonemic verbal production is usually less affected in these patients [52]. A disorder is indicated by a number of animals named lower than 15 per minute [14]. If the patient names 15–9 animals, it is a mild disorder. Listing 0–8 animals is a severe disorder. This is clearly shown in Table 2. The advantage of the test is its simple administration. To ensure the objectivity and accuracy of the results, it is important to standardize the testing conditions (e.g., duration, clear instructions).

 

Cognitive tests longer than 10 minutes

Addenbrooke's Cognitive Examination

The third version of the Addenbrooke's Cognitive Examination (ACE-III) has been available since 2013 after its validation for patients with frontotemporal dementia (FTD) and AN [15]. The psychometric properties are described in Table 1. After more than 10 years, the Czech version of ACE-III-CZ was validated for the assessment of cognitive functions. A study of 60 individuals (30 with AN, 30 healthy) confirmed that the test reliably distinguishes AN from healthy individuals, especially in memory and language subtests [53]. A Japanese study from 2019 validated the test for the detection of MKP [16]. The test contains 18 tasks in five cognitive areas: attention, memory, executive functions, visuospatial abilities, and speech. Administration takes 15–30 minutes using several recording sheets. The maximum score is 100 points, with normal performance corresponding to approximately 90–100 points according to the previous revised version. There are no Czech norms for ACE-III. The test contributes to the differential diagnosis between AN (memory deficits) and FTD (executive and language deficits) [54].

 

Montreal Cognitive Assessment (MoCA)

The Montreal Cognitive Assessment (MoCA) was introduced in 2005 and is used for rapid screening of MCI [17]. In 2018, the Czech version of MoCA-CZ was validated on 1,553 people (aged 60–96) for the diagnosis of MCI and early stages of AD [19]. Healthy seniors scored an average of 26 points, patients with MCI scored 22–24 points, and patients with dementia in AN scored below 20 points. The MoCA takes 10–15 minutes to administer and assesses multiple cognitive functions (memory, executive function, language, visuospatial abilities, and attention). The maximum score is 30 points, with a cut-off score of 24 points for the Czech population [19]. According to the original Canadian study, the cut-off score was 26 points [17]. A large meta-analysis showed a cut-off value of 23 points, which is consistent with the Czech study [14,18]. Mild cognitive impairment is between 23 and 19 points and severe impairment is less than 18 points, as shown in Table 2. The MoCA test is more sensitive than the MMSE for early cognitive impairment. Its psychometric properties are shown in Table 1. Due to its difficulty, it is not suitable for advanced dementia. Successful completion of official training and certification is mandatory for anyone administering the MoCA test in paper form. Training and certification are subject to a fee, but are currently free for students, academics, researchers, and public health institutions upon presentation of proof of status [55].

The one-page record sheet does not contain precise instructions on how to correctly perform, administer, and, most importantly, evaluate the test, so testers may make mistakes if they do not know or remember the multi-page instructions.

Since the ALBA and POBAV tests correlate significantly with the MoCA test, its results can be estimated from the scores of very short tests according to these regression equations: 1) MoCA score = 17.3 + 1 × ALBA score, which actually means that the MoCA score can be simply calculated as the ALBA memory score + 17 points = MoCA-CZ score. 2) MoCA score = 20.97 + 0.55 × picture recall score in the POBAV hedgehog test.

 

Tests for impaired self-sufficiency in dementia syndrome

Very short tests lasting up to 5 minutes

Clock drawing test

The clock drawing test is a quick screening tool for examining patients with dementia, but it is not suitable for detecting MKP [56]. It is part of many comprehensive short tests. It assesses long-term memory, visuospatial abilities, calculation, and executive functions. It cannot be used to test short-term memory. The patient is asked to draw a clock face with all the numbers and correctly place the hour and minute hands at a specific time, usually 11 : 10 or, more challenging, 23 : 20 [20]. One possible scoring system is BaJa, which gives greater weight to the correct placement of the hands than to the simple clock face [20]. The test and evaluation take a maximum of 2 minutes. Errors such as incorrect time, incorrect or misplaced numbers indicate cognitive impairment. Scores for mild and severe impairment are shown in Table 2. Patients with Lewy body dementia have obvious difficulties with this simple task, sometimes despite performing quite well on other short tests. The characteristics of this test are shown in Table 1.

 

Mini-Cog test

Introduced in 2000, this test is a short screening test for the detection of dementia with a sensitivity of 76–99% and a specificity of 89–93% [57]. The Mini-Cog test combines a clock drawing test with a memory task. The patient first memorizes three words from six available versions for repeated testing. In the second step, the patient draws a clock with the hands set at 10 minutes past eleven. The patient then has to recall as many of the three words as possible. A 2003 validation study of 1,119 people (aged 65+) confirmed its suitability for dementia screening [58]. According to recent meta-analyses, diagnostic accuracy is difficult to assess due to the high risk of bias in individual studies. The sensitivity and specificity of the latest meta-analysis from 2024 are shown in Table 1 [23]. The clock test does not focus on memory, and three words to remember are insufficient because the capacity of short-term memory is 7 ± 2 items. In the Czech Republic, general practitioners can use this test as a tool for assessing cognitive impairment in patients between 65 and 80 years of age, even though the test has not yet been validated in our country [7]. The test takes 2–3 minutes to complete and evaluate. According to the official website, the test is suitable as a screening tool for dementia, but currently, the detection of MCI is more important. Copies may be made with the author's consent exclusively for clinical and educational purposes. It may not be modified or used for marketing, advertising, or research purposes without the author's prior written consent.

 

Longer cognitive test

Mini-Mental State Examination (MMSE)

In 1975, the MMSE was developed and validated as a rapid tool for assessing cognitive function [59]. According to a Czech study, a score of 27 points is considered the borderline score, with the normal range being 28–30 points. Mild cognitive impairment is between 24–26 points and severe impairment is less than 23 points (Table 2) [26]. The sensitivity and specificity of the MMSE are shown in Table 1. The MMSE test is the most widely used method for assessing cognitive function and serves as a reference tool. Since 2025, the prescription of cognitive drugs has no longer been linked to the MMSE score. Therefore, any test can be used to assess cognition. The reason for this is that the MMSE has been protected by copyright since 2001 and its use is subject to a fee [60]. The price for a single use is approximately USD 2. Without purchasing a license from this American private company, further use of the test in the Czech Republic is not legal. The test focuses on orientation, memory, and language [61]. The test takes 5–10 minutes to complete and evaluate, but according to the official website of the copyright holder, it takes 10–15 minutes to complete, plus 5 minutes for evaluation. However, the MMSE test is not sensitive enough to detect MCI or early stages of dementia [25]. Some authors argue that the MMSE is not accurate enough for modern diagnostic needs. The availability of newer, more valid and sensitive tools, such as MoCA, challenges the position of MMSE in clinical practice [61]. The MMSE result can be estimated from the ALBA scores using this regression equation: MMSE score = 20.7 + 0.7 × ALBA score [27].

 

Digital tests and telemedicine examinations

In recent years, computer-based cognitive screening tools have become increasingly common. Compared to traditional paper-and-pencil testing, computer-based tests have a number of advantages—they reduce costs, increase standardization, and minimize bias. At our workplace, we have verified that the results of telemedical examinations using the ALBA, POBAV, and ACE-III tests are comparable to the results of personal examinations [62]. The Czech Republic has developed a unique and first Czech test, ALBAV, for electronic self-examination of memory, which is validated for the electronic detection of mild cognitive impairment [63,64]. The Czech digital application called ALBAV is available for computers on the website [65].

 

Recommendations for clinical practice

An undiagnosed cognitive disorder can have significant health, social, and occupational consequences. It is often impossible to detect from a normal conversation, especially in the early stages. Therefore, it is necessary to use any short cognitive test in clinical practice. We have classified the cognitive tests presented according to their purpose and duration. An overview and comparison of these tests is provided in Tables 1, 2, and 5AB [66–70]. For general practitioners, very short tests lasting up to 5 minutes, such as Mini-Cog, ALBA, and POBAV, are recommended [7]. Since 2025, there has been a change in the requirements for prescribing cognitive tests. It is no longer a requirement to use the MMSE test alone, but it is necessary to demonstrate cognitive impairment. In the diagram in Fig. 4, we propose one possible procedure. This algorithm is mainly focused on the rapid detection of cognitive impairment due to the high number of patients that doctors have to see. For the initial assessment of cognitive functions, it is advisable to choose tests that are very short and at the same time demanding. Such methods include the ALBA and POBAV tests. Based on a combination of their results, cognitive impairment may be present with varying degrees of probability. In the case of ambiguous or unclear findings, or in certain situations, it is advisable to extend the examination with additional tests or to repeat them after 3–6 months. Both tests are also useful for monitoring the course of cognitive functions due to their duration of 6–8 minutes. Cognitive impairment can be confirmed or refuted by other short or longer tests or neuropsychological examinations. If self-sufficiency is maintained when considering MKP, there is no point in performing the MMSE test, as the result will be normal or close to normal. More comprehensive MoCA or ACE-III tests can be chosen if there is sufficient time and knowledge to perform, score, and interpret them correctly. For patients who are dependent on the help of others, and therefore suspected of having dementia, we can choose less demanding tests such as the clock drawing test and Mini-Cog after testing ALBA and POBAV. In advanced dementia, it is more appropriate to assess dependence rather than cognitive testing, as it has a greater practical impact.

 

Grant support

This work was supported by projects COOPERATIO Q38 of Charles University, RVO [Královské Vinohrady University Hospital, 00064173] and the Technology Agency of the Czech Republic within the SIGMA DC3 Program [TQ01000332 Telemedical self-examination of speech and memory for rapid detection of cognitive disorders using machine   learning].

 

Conflict of interest

MUDr. Magda Michalovová has no conflict of interest. Prof. MUDr. Aleš Bartoš, Ph.D., developed the ALBA and POBAV tests.

 

Table 1 Overview of the psychometric properties of short cognitive tests.

Test (point range)	Degree of cognitive impairment	Borderline score	Sensitivity (%)	Specificity (%)	Area under the ROC curve	Source
ALBA (0–12 points)	Mild cognitive deficits	≤ 8 points	90	77	0.90	Bartos and Diondet (2024) [11]
POBAV hedgehog –⁠ naming errors (0–20 points)	very MKP	≥ 0 errors	100	0	0.59	Bartos and Diondet (2024) [12]
Hedgehog POBAV –⁠ picture equipment (0–20 points)	very MKP	≤ 8 correctly equipped images	63	75	0.76	Bartoš and Diondet (2024) [12]
POBAV hedgehog –⁠ naming errors (0–20 points)	mild dementia in AN	≥ 0 errors	59	83	0.77	Bartoš (2016) [13]
Hedgehog POBAV –⁠ picture equipment (0–20 points)	mild dementia in AN	≤ 6 correctly equipped pictures	100	97	0.99	Bartoš (2016) [13]
Animal verbal production test	MKP in AN	≤ 17 named animals	82	79	0.93	Bartoš and Raisová (2019) [14]
	dementia in AN	≤ 15 animals listed	85	87	0.94	Bartoš and Raisová (2019) [14]
ACE-III (0–100 points)	Mild dementia in AN, FTD	≤ 88 points	100	96	–	Hsieh et al. (2013) [15]
	dementia	≤ 75/76	82	90	0.94	Takenoshita et al. (2019) (meta-analysis) [16]
	MKP	≤ 88/89	77	92	0.91	Takenoshita et a al. (2019) (meta-analysis) [16]
MoCA (0–30 points)	MKP	≤ 26	90	87	–	Nasreddine et al. (2005) [17]
	mild dementia in AN	≤ 26	100	87	–	Nasreddine et al. (2005) [17]
	MKP	≤ 24 points	88	88	–	Carson et al. (2017) (meta-analysis) [18]
	MKP in AN	≤ 24 points	87	72	0.89	Bartoš and Fayette (2018) [19]
	Very MKP	≤ 24 points	56	76	0.74	Bartoš and Diondet (2024) [12]
Clock drawing test 23 : 20 with BaJa scoring (0–5 points)	MCP and mild dementia	≤ 4 points	65	59	0.70	Bartoš (2016) [20]
Clock drawing test (different scoring) (variable)	–	not possible	41–85	44–85	0.60–0.73	Patnode et al. (2020) [1]
Mini-Cog (0–5 points)	Dementia in primary care	not possible	76	73	–	Seitz et al. (2021) [21]
	dementia	not possible	76	89	–	Borson et al. (2003) [22]
	dementia	not possible	76	83	–	Abayomi et al. (2024) (meta-analysis) [23]
	MKP	Not possible	84	79	–	Abayomi et al. (2024) (meta-analysis) [23]
MMSE (0–30 points)	MKP	26/27	69	77	–	Kalbe et al., 2004 [24]
	MKP in AN	≤ 27 points	74	79	0.83	Bartoš and Raisová (2016) [14]
	Mild dementia in AN	≤ 27 points	82	89	0.93	Bartoš and Raisová (2016) [14]
	Dementia in primary care	not possible	78	88	–	Mitchell et al. (2009) (meta-analysis) [25]

ACE-III-CZ –⁠ Addenbrooke's Cognitive Examination III; AN –⁠ Alzheimer's disease; ALBA –⁠ Amnesia Light and Brief Assessment; MCP –⁠ mild cognitive impairment; MMSE –⁠ Mini-Mental State Examination; MoCA –⁠ Montreal Cognitive Assessment; POBAV –⁠ Naming Pictures and Their Equipment, ROC –⁠ Receiver Operating Characteristic

 

 

Table 2. Classification of short cognitive test scores as normal, mildly abnormal, and clearly abnormal.

Mild cognitive impairment corresponds approximately to mild cognitive impairment, severe cognitive impairment to dementia, but they are not synonymous, because the degree of self-sufficiency is important in the diagnosis of syndromes. Please note that this is only a classification based on test scores. However, when assessing a person, it is necessary to base the assessment on a comprehensive examination, especially a current assessment of self-sufficiency. The table is based on actual data in relevant publications, where more accurate norms and score distributions by percentile can be found.

Test, number of persons, and source of standards		Standard (approximately higher than the 16th percentile)	Mild cognitive impairment (approximately 2nd–16th percentile)	Severe cognitive impairment (approximately lower than the 2nd percentile)
ALBA (n = 560, Bartoš and Diondet, 2024 [11])	No high school diploma	12–6 points	4–5 points	0–3 points
	With high school diploma	12–7 points	4–6 points
Door version of the POBAV test (n = 260, not yet published)	Name	0–1 error	2–3 errors	4 or more errors
	Equipment	6 or more pictures (borderline 5–8 depending on age, education, and gender)	3–5 pictures or, more precisely, up to the borderline number of correctly equipped pictures	0–2 equipped images
Hedgehog version of the POBAV test (n = 965, not yet published)	Naming	0–1 error	2 errors	3 or more errors
	Equipment	7 or more images (range 5–8 depending on age, education, and gender)	3–6 or, more precisely, up to the borderline number of correctly equipped pictures	0–2 correctly matched images
Cognitive profiles according to three ALBA and POBAV test scores (based on logical reasoning)		profile 1 –⁠ all normal, borderline result with profiles 2–4 with one abnormal score	profiles 5–7 with two abnormal scores	profiles 8–10 with three abnormal scores
Animal verbal production test in 1 minute (n = 1,642, Bartoš and Raisová, 2019 [14])		16 or more animals	15–9 animals	0–8 animals
MoCA (n = 1,552, Bartoš and Fayette, 2018 [19])		30–24 points	23–19 points	18 points and below
Clock drawing test 23 : 20 with BaJa scoring (n = 77, Bartoš and Raisová, 2019 [14])		5 points	4–2 points	0–1 point
MMSE (n = 650, Bartoš and Raisová, 2016 [26])		30–27 points	26–24 points	23 points and below

ALBA –⁠ Amnesia Light and Brief Assessment; MMSE –⁠ Mini-Mental State Examination

(note: Czech standards are missing for the 3rd version of the Addenbrooke's Cognitive Examination and Mini-Cog);

MoCA –⁠ Montreal Cognitive Assessment; POBAV –⁠ Naming Pictures and Their Equipment

 

 

Table 3 Cognitive profiles based on a combination of three scores derived from the ALBA and POBAV cognitive tests (ALBA memory score, number of errors in naming pictures, number of correctly named pictures).

Cognitive profile	ALBA	POBAV			Verbal comment
Number		NAME		EQUIPMENT
1	N	N		N	All results within normal range
2	N	N		ABN	Only the number of equipped image names in the POBAV test is pathologically isolated.
3	N	ABN	3	N	Only the number of errors in naming pictures in the POBAV test is pathologically isolated.
4	ABN	N		N	Only the memory score in the ALBA test is pathologically abnormal.
5	N	ABN	5	ABN	ALBA's score is normal, the scores for both parts of the POBAV test are pathological
6	ABN	N		ABN	ALBA's score is pathological, and at the same time, in the POBAV test, only the number of equipped image names is pathological.
7	ABN	ABN	4	N	ALBA's score is pathological, and at the same time, in the POBAV test, only the number of errors in naming pictures is pathological ( ).
8	ABN	ABN ↑	<	ABN ↓	The ALBA score is pathological, and at the same time, in the POBAV test, the number of errors in naming pictures is 2 or more less than the number of correctly named pictures.
9	ABN	ABN ↑↑	=	ABN↓↓	The ALBA score is pathological, and at the same time, in the POBAV test, the number of errors in naming pictures is equal to or differs by exactly one picture name compared to the number of correctly named pictures.
10	ABN	ABN ↑↑↑	>	ABN↓↓↓	ALBA's score is pathological, and at the same time, in the POBAV test, the number of errors in naming pictures is greater by 2 or more than the number of correctly named pictures.

ABN –⁠ abnormal score (lower or higher than the threshold score according to age and education); ALBA –⁠ Amnesia Light and Brief Assessment; POBAV –⁠ Naming Pictures and Their Equipment; N –⁠ normal score

 

 

 

Stage	ALBA memory score (0–12 points)	POBAV (0–20 pictures recalled)	Medicine	Insurance coverage	Additional information
Mild cognitive impairment (MCI)	4–5 points (without high school diploma) 4–6 points (with high school diploma)	3–5 images	IAChE (e.g., donepezil)	❌ no	Insurance company does not cover due to lack of evidence; patient pays for treatment themselves
Mild dementia	4–5 points (without high school diploma) 4–6 points (with high school diploma)	3–5 images	IAChE	✅ yes	must also document impairment of self-sufficiency (e.g., interview, Functional Status Questionnaire [FAQ]), comprehensive examination every 3–6 months
Moderate dementia	2–3 points	2–3 images	IAChE + memantine (possible combination)	✅ yes	Proof of dependence required, comprehensive examination every 3–6 months
Severe dementia	0–1 point	0–1 image	Memantine	✅ yes	The degree of dependence is decisive; the score is only indicative; treatment is discontinued if the condition worsens.

Table 4 Prescription of acetylcholinesterase inhibitors (AChE: donepezil, rivastigmine, galantamine) and memantine according to the degree of cognitive impairment, ALBA and POBAV scores in accordance with the new criteria of the insurance company from 2025.

ALBA –⁠ Amnesia Light and Brief Assessment; IAChE –⁠ acetylcholinesterase inhibitors; POBAV –⁠ Picture Naming and Picture Completion

 

 

Table 5. Short cognitive tests according to their characteristics (A) and advantages and disadvantages (B).

A

Test and source	Indications	Type of cognitive functions examined	Test score range	When to use the test	Test duration (minutes)
ALBA [65]	MKP	Episodic and short-term memory, testing of speech abilities (aphasia), detection of apraxia	0–12 points	Examination of memory disorders in the early stages, assessment of development, assessment of episodic memory, screening examination of phatic functions	2–3
POBAV [65]	MCP, mild dementia	Semantic, short-term memory, graphia, naming (nomie)	Number of incorrectly named pictures (preferably 0), number of correctly named pictures (out of a total of 20 pictures)	Examination of memory disorders in the early stages, assessment of development, assessment of nomie, graphia	4–5
Animal verbal production test (categorical production)	MCP, mild dementia	semantic memory, attention, executive and speech abilities	number of animals named in one minute	testing of executive and semantic abilities and psychomotor speed	up to 2
ACE-III-CZ [66]	MCP, mild dementia	immediate and delayed memory, semantic memory, visuospatial abilities, language abilities, attention	0–100 points	more detailed examination of cognition, early diagnosis of memory disorders, differential diagnosis of individual types of dementia, assessment of development	15
MoCA [67]	MKP	memory, executive functions, visuospatial abilities, speech, temporal and spatial orientation	0–30 points	examination of patients with cognitive difficulties and normal self-sufficiency	10–15
Clock drawing test [65]	Dementia	executive functions, visu nd spatial abilities, calculation, memory	max 5 points when scoring BaJa	screening examination for dementia	1–3
Mini-Cog [68]	dementia	executive functions, visuospatial abilities, calculation, semantic and remote memory	0–5 points	screening test for dementia	3–5
MMSE [69]	dementia	memory, speech, temporal and spatial orientation, reading, writing, attention, counting	0–30 points	rapid and preliminary quantification of cognitive impairment, monitoring of development	5–10

 

B

Test	Advantages	Disadvantages
ALBA	Original Czech test, no aids required, short duration, examination of episodic memory (e.g., medication use), examination of phatic functions and apraxia, can be performed at the bedside or in the emergency room, even for patients with paresis of the dominant limb, visually impaired or blind patients, validated on the Czech population, Czech standards, free of charge	no testing of other cognitive functions, difficult to use in patients with hypacusis
POBAV	Original Czech test, short duration, detection of very mild cognitive deficits, existence of a validated and comparable alternative version for repeated testing, patient fills out most of it themselves, oral version available for patients with paresis of the dominant limb, validated for the Czech population, Czech standards, free of charge	Requires a pre-printed sheet, does not cover multiple cognitive functions, requires the use of a stopwatch/watch
Animal verbal production test (categorical production)	Demanding test, short duration, Czech standards exist for the healthy senior population of the Czech Republic, free of charge, no test form required	verbal only, stopwatch/watch required
ACE-III-CZ	assessment of global mental level (5 subscales), suitable for differential diagnosis of types of dementia, assessment of delayed recall, free of charge	requires the use of several recording sheets, long to perform and evaluate, more complex evaluation, not suitable for routine repeated examinations
MoCA	more comprehensive examination of cognitive functions, relatively demanding tasks for detecting MCI, Czech standards for a large group of the senior population	fee for training in the test, assigns the same number of points for cognitively different tasks, longer duration and administration, tasks with repetition of a specific task
Clock drawing test	simple task, performed independently by the examinee, very well known, short duration	does not capture MKP, difficult scoring, high variability of errors, difficult to perform in patients with paresis of the dominant limb/fine motor skills disorder
Mini-Cog	Simple task, quick to perform, freely available, Combines two tests into one (clock drawing test, short-term memory test with delayed recall)	high variability of errors, high variability of errors in the clock drawing test, difficult to perform in patients with paresis of the dominant limb/fine motor skills impairment, not validated on the Czech population, no Czech standards, 3 words to test memory are insufficient, insufficient scoring of clock drawing, problematic scoring of clock drawing (the length of the hands does not matter)
MMSE	Comprehensive examination of cognitive functions, simple evaluation	fee for use of the test, does not detect MCP, requires a pre-printed sheet, insufficient memory test

ACE-III-CZ –⁠ Addenbrooke's Cognitive Examination III; ALBA –⁠ Amnesia Light and Brief Assessment; MCP –⁠ mild cognitive impairment; MMSE –⁠ Mini-Mental State Examination; MoCA –⁠ Montreal Cognitive Assessment; POBAV –⁠ Naming Pictures and Their Equipment