Abstract
Objectives: The Mini-Cog, a rapid, valid, and reliable screening tool for cognitive impairment, consists of 3-word
recall and an executive Clock-Drawing Test (CDT).However, CDT requires at least basic literacy and cultural
exposure to analog clocks, conditions not met in many population groups around the world. We developed a
modication of the Mini-Cog (MMC) for use with non-literate and literate individuals.
Methods: Participants were adults (≥ 60 years) with no neurological diagnosis, with known cognitive impairment
due to stroke, Parkinsonism, traumatic brain injury or Alzheimer’s disease, and whose family members were able
to read and write. We replaced the CDT with two tasks of everyday life: a serial subtraction task or a multistep
performance task. Family members rated the acceptability and feasibility of the Mini-Cog versions using a 6-
point scale, and completed a proxy-rated cognitive staging tool, the Dementia Severity Rating Scale (DSRS).
Spearman’s rho, Mann- Whitney U and Chi-square tests were used to evaluate group differences and associations
between measures.
Results: Data were collected from 63 participants (75% ≥ 60 years, 67% non-literate). Literacy was associated
with CDT (Chi-square strength 0.9, p < 0.001).Both MMC versions correlated with DSRS in healthy adults and
patients (rho 0.6-0.7, p < 0.05). In literate individuals, the acceptability and feasibility of CDT and both alternate
distractors were similarly high (5/6).
Conclusions:Two alternate distractor tasks may successfully replace CDT in the Mini-Cog. The MMC versions
are promising and deserve further study as screening tools for cognitive impairment in larger and more fully
characterized samples.
Background
The Mini-Cog (MC) is a short screening tool for clinically important cognitive impairment, originally developed by
Borson et al., in 2000 by combining a short memory test and an executive clock-drawing test (CDT) (1). The
choice of 3-item recall as the memory test was based on research showing that this element in the Mini Mental
State Examination (MMSE) is the rst to be impaired in early Alzheimer's disease (1, 2). The CDT serves as an
informative distractor: it creates a short recall delay and itself functions as a cognitive test, since it relies on
multiple integrated cognitive functions commonly impaired in neurocognitive disorders. The MC is feasible,
reliable, valid and time saving for settings in which rapid detection of cognitive impairment is desirable, since it
takes just 3 minutes to administer (1, 3). It has acceptable sensitivity and specicity for dementia in both clinical
and population samples, detects mild cognitive impairment (with less sensitivity and specicity), and has been
widely implemented in western clinical settings (1, 2, 4). McCarten and colleagues highlighted its speed and high
acceptance by older veterans (5). Studies have also reported superior screening properties of the MC compared
to that of MMSE (1, 6) and its psychometric properties have been well established (1, 7). Both components of the
MC contribute to detection of dementia (2).
The Mini-Cog is available in many languages (mini-cog.com) and has been used successfully in the United
States with both English and non-English speakers with varying levels of education, but its clock drawing
component is vulnerable to very low education – uncommon in US-born populations and poorly represented in
most research on cognitive impairment. The CDT may not be valid with non-literate individuals, as it generally
requires at least a basic education (typically 4–5 years of primary schooling); while oral 3-word recall should not
