The Mini-Cog© has been tested with two different time settings (11:10 and 8:20) with similar results. However, 11:10 may have a theoretical added advantage: the proximity of the 10 and 11 on the clock face may induce some individuals to place the hands pointing to those two numbers, unmasking subtler executive deficits.
Some clock scoring systems require different hand lengths for full credit; the Mini-Cog© algorithm does not, because hand length does not strongly contribute to the accuracy of cognitive classification with this tool.
We don’t show more obviously abnormal clock drawings on this website (for example, no numbers, multiple repeats of the same number, or completely disorganized drawing). This is because obvious errors are obvious to everyone! We want users who administer the Mini-Cog© to be alert also to more subtle abnormalities like those we illustrate here.
The Mini-Cog© was developed to require minimal training and no clinical background in a cognitive disorders field. Both components can be reliably administered and scored by any member of the health care team, and detailed instructions are provided on the standardized form. Most health care systems have determined the workflow that is best for them, often designating a medical assistant or rooming nurse for this purpose. In some settings, a nurse or physician is expected to interpret (score) the clock drawing. Below is a table with examples that may appeal to health systems incorporating the Mini-Cog© to screen for cognitive impairment in the Medicare Annual Wellness Visit.
|Trained Lay Healthcare Worker
|Administer the entire screen as a unit (both the word recall and clock drawing).
|Score the 3-item recall, and show the clock to RN or physician for scoring. Bring all screen results to the attention of the team RN, ARNP, or physician.|
|Score both the 3-item recall and clock drawing. Bring abnormal results to the physician’s attention|
|Score both the 3-item recall and clock drawing. Interpret results to the patient/family if present, and determine next steps to further evaluate the basis for an abnormal result.|
The Mini-Cog© score should be documented in the electronic health record. The exact method or place for documentation varies by institution. Many institutions prefer that documentation be consistently entered into a discrete field so that reports can be generated for the purposes of quality improvement and research. At a minimum, it is desirable to record which word list version was used and the score on each test component (recall and clock drawing).
The Mini-Cog© is not a diagnostic test. It is a screening tool, and it needs to be followed up with other kinds of testing to determine the cause and effect of the problem. Failing a properly administered Mini-Cog© is a pretty good indicator that cognitive impairment is present at the time of testing, but it does not provide clues to the cause. Occasionally, cognitive impairment detected by the Mini-Cog© can be a temporary result of a medical illness, a drug, or other condition and should be followed up.
When an individual fails the Mini-Cog©, the first step is a gentle disclosure that there could be a problem with memory or thinking and an initial inquiry about whether he/she has noticed any problems or the family has mentioned any changes. When a family member has accompanied the patient, discussion of the results with both the patient and family is usually appropriate. When the patient has come alone, arranging for a follow up visit that includes key family or friends is important, as people close to the patient can provide valuable information about the history and effects of cognitive difficulties. Reviewing the patient’s medical history and medications for possible contributing factors are essential early steps in the evaluation (Cordell et al. 2013).
You are surprised – and the patient has no complaints. This can be an awkward moment for a healthcare provider! It is important to be prepared. You might say something like, “it seems you might have a bit of a problem with your memory or thinking. This is something we should follow up on because it could represent a health problem that we didn’t know was there. I would like you to come back to see me and we’ll talk about it some more.” Then be sure an appointment is made, and that it includes someone who knows the patient well and will come with the patient (e.g. spouse, partner, family member, close friend).
No – the Mini-Cog© is a screening test, not a diagnostic assessment. It can be normal in some individuals who have clinically relevant cognitive impairment, especially those with very mild cognitive impairment or high prior intellectual ability. Whenever a patient, their doctor, another healthcare provider, or a family member is concerned about changes in his/her cognitive functioning, follow up with additional evaluation and assessment.