Bedside cognitive testing
The MMSE is not free to reproduce, and most clinicians find out late. What you can use, and how to test orientation, attention and memory without any instrument at all.
Cognition is the domain most often skipped, and the one where skipping is most consequential. An acute confusional state can look like psychosis, like depression, and occasionally like personality, and the thing that distinguishes it is a few minutes of bedside testing.
There is also a practical obstacle that trainees discover late: the instrument you were taught to use may not be free to use.
The licensing problem nobody mentions
The Mini-Mental State Examination is the test most clinicians learned first, and it is copyrighted. The rights are held by Psychological Assessment Resources, following assignment from MiniMental LLC in 2001, and PAR sells licensed copies per administration.
This is why the MMSE quietly disappeared from textbooks and pocket guides. Reproducing it — in a handbook, on a ward proforma, or in software — requires a licence.
The Montreal Cognitive Assessment sits in a middle position. It is free for clinicians and health institutions to use, but commercial entities require prior written permission and a licensing agreement, and administration now requires training and certification.
A ward proforma, a digital form, an app: check the licence before embedding an instrument. "Everyone uses it" is not a defence, and the rights holders do enforce. MHABot deliberately embeds no copyrighted cognitive test — it provides a free-text field for you to record the instrument and score yourself.
Which instruments are actually free
| Instrument | Status | Practical note |
|---|---|---|
| MMSE | Copyrighted, licensed per use | Do not reproduce without a licence |
| MoCA | Free for clinical use; commercial use needs an agreement | Training and certification now required |
| ACE-III | Free for clinical and educational use, but licensed | Check terms before any digital or commercial use |
| AMTS (10-item) | Long-standing, widely reproduced, effectively public domain | Quick, low risk, useful for a rapid screen |
| 4AT | Explicitly free for clinical use and download | Designed for delirium; must not be modified |
| PHQ-9, GAD-7 | Free, no permission required | Mood and anxiety rather than cognition, but useful to know |
| AUDIT | WHO instrument, free with attribution | Alcohol screening |
The AMTS and the 4AT between them cover most of what a general psychiatric assessment needs, and neither carries a licensing problem. The 4AT in particular was designed for rapid delirium detection in unselected patients and takes about two minutes.
Bedside testing without any instrument
You do not need a form to establish whether someone is oriented, attentive and able to retain information. What follows is standard bedside enquiry, useful in itself and defensible as a record.
Introduce it plainly. "I am going to ask you a few questions to check your concentration and memory. Some are easy — I ask everyone." Without that, the questions feel like a test the person may resent or fear failing.
Orientation
"Can you tell me where we are at the moment?"
"Do you know what day of the week it is? And roughly the date?"
"What time of day would you say it is?"
"Do you know why you have come here today?"
Disorientation typically appears in a rough order: time first, then place, then person. Being disoriented in person while oriented in time is unusual and should prompt thought about whether something other than a confusional state is happening.
Orientation to situation — knowing why they are here — is often the most informative and the most often omitted. It also sits close to insight.
Attention and concentration
Attention is the core deficit in delirium, which makes this the highest-yield part of the domain.
"Can you tell me the months of the year backwards, starting with December?"
"Can you take 7 away from 100, and keep going?"
Months backwards is better for most psychiatric settings: it is less dependent on education and numeracy, it takes under a minute, and failure is easier to interpret. Serial sevens penalises people who were never confident with arithmetic, and you will not always know that in advance.
Record what happened rather than a verdict. "Able to recite the months backwards to August, then lost the sequence and restarted twice" is a finding. "Attention impaired" is a conclusion the next clinician cannot check.
Memory
"I am going to say three words and ask you to repeat them. Then I will ask you again in a few minutes." — a common set is apple, table, penny.
"What did you have for breakfast?"
"How did you get here today?"
"Where did you go to school?"
"What is the earliest thing you can remember clearly?"
Recent memory questions are only useful if the answer can be checked, so prefer ones a relative or the notes can verify. An unverifiable answer given fluently tells you about fluency, not memory.
The question that matters most
Beyond any individual test: has this changed, and does it fluctuate?
Delirium is defined by acute onset and a fluctuating course, and neither is detectable from a single bedside examination. They come from collateral history and from nursing observations across a shift.
A person who was cognitively intact last week and is disoriented today has an acute confusional state until proven otherwise, and needs a physical cause excluded before anything is attributed to a psychiatric illness. New confusion in an older adult is a medical emergency, not a psychiatric presentation with an unusual flavour.
Two questions to whoever knows them: "Is this how they normally are?" and "Has it been coming and going, or is it constant?" They take ten seconds and change the differential entirely.
Recording it
Say what you tested, what happened, and what you did not test.
He was oriented in place and person but gave the date as three days earlier and was unsure of the day of the week. He recited the months backwards to September before losing the sequence, restarting twice. He recalled two of three words at three minutes. Recent memory appeared intact for events his sister was able to confirm. His sister reports that this is a change from a week ago and that it has been worse in the evenings. Formal cognitive testing was not undertaken at this contact.
That paragraph does something a score cannot: it says what the person actually did, marks the change and the fluctuation from collateral, and states plainly that no formal instrument was used. A reader can form their own view rather than inheriting yours — and the fluctuation, which is the most important thing in it, would not appear in any single-administration score at all.
Common questions
Is the MMSE free to use?
No. The Mini-Mental State Examination is copyrighted, with rights held by Psychological Assessment Resources following assignment from MiniMental LLC in 2001, and licensed copies are sold per administration. This is why it disappeared from textbooks and pocket guides. Reproducing it in a proforma or in software requires a licence.
Which cognitive screening tools can I use without a licence?
The AMTS is long-standing and effectively public domain. The 4AT is explicitly free for clinical use and download, provided it is not modified. The MoCA is free for clinicians and health institutions but requires an agreement for commercial use, and now requires training. ACE-III is free for clinical use but licensed, so check the terms before any digital use.
How do I test attention at the bedside?
Months of the year backwards, starting with December, is the most useful single task in a psychiatric setting: it takes under a minute and depends less on education and numeracy than serial sevens. Record what actually happened rather than a verdict — where they lost the sequence and how many times they restarted.
What is the difference between delirium and a psychiatric presentation?
Delirium is defined by acute onset, a fluctuating course, and impaired attention as the core deficit. Neither the onset nor the fluctuation is visible in a single bedside examination, so both come from collateral history. New confusion in an older adult should be treated as a medical emergency until a physical cause is excluded.
Do I have to do formal cognitive testing in every assessment?
No, but you should record what you did and did not do. A silent gap in the cognition domain will be read as cognition having been unremarkable. One sentence stating that formal testing was not undertaken at this contact converts an omission into a documented decision.