Question 1 – What year is it? (Orientation)
The exact year must be given, however an incomplete numerical value for the year (e.g. 11 instead of 2011) is accepted as correct
Scoring: The patient will score 0 for a correct answer and 4 for an incorrect answer
Question 2 – What month is it? (Orientation)
The exact month must be given, however a numerical value for the month (e.g. 10 for October) is accepted as correct
Scoring: The patient will score 0 for a correct answer and 3 for an incorrect answer
Question 3 – Memory – Part 1
In this part of the questionnaire, the practitioner gives the patient a name and address with five components to remember, e.g., John, Smith, 42, High Street, Bedford (this is to be recalled after question 6). The practitioner should say “I will give you a name and address to remember for a few minutes. Listen to me say the entire name and address and then repeat it after me.” The trial should be re-administered until the subject is able to repeat the entire name and address without assistance or until a maximum of three attempts. If the subject is unable to learn the entire name and address after three attempts, a “C” should be recorded. This indicates the subject could not learn the phrase in three tries. Whether or not the name and address is learned, the clinician should instruct “Good, now remember that name and address for a few minutes”
Question 4– About what time is it? (Orientation)
A correct response should be given without the participant referring to a watch or clock and should be accurate to ±1 h. If the answer given is rather vague (e.g. “almost 2 pm”) the patient should be prompted for a more specific answer
Scoring: The patient will score 0 for a correct answer and 3 for an incorrect answer
Question 5– Count backwards from 20 to 1 (Calculation)
If the patient skips a number after 20, an error should be recorded. If the patient starts counting forward or forgets the task at any point, the instructions should be repeated and an error recorded
Scoring: The patient will score 0 for a correct answer (no errors), 2 points for 1 error and 4 points for more than 1 error
Question 6 – Say the months of the year in reverse (Calculation)
To get the subject started, the examiner may state, “Start with the last month of the year. The last month of the year is: (patient to fill in the gap)”
If the patient cannot recall the last month of the year, the examiner may prompt with “December”. However, one error should be recorded. If the patient skips a month, an error should be recorded. If the patient begins saying the months forward upon initiation of the task, the instructions should be repeated and no error recorded. If the patient starts saying the months forward during the task or forgets the task, the instructions should be repeated and one error recorded
Scoring: The patient will score 0 for a correct answer (no errors), 2 points for 1 error and 4 points for more than 1 error
Memory – Part 2 – Repeat the name and address I asked you to remember
The patient should state each item verbatim. The address number must be exact (e.g. 420 instead of 42 is incorrect). Omitting the thoroughfare term (street, road, drive, crescent) from the street-name or substituting it for a different one will not constitute an incorrect answer- score as correct
Scoring: The patient will score 0 for a correct answer (no errors), 2 points for 1 error, 4 points for 2 errors, 6 points for 3 errors, 8 points for 4 errors and 10 points if they got all of the components wrong
Unlike the majority of cognitive screening instruments, 6CIT uses an inverse scoring method (0–28, normal to impaired) with question scores weighted to produce the total score out of 28 (see Table 11.1 for scoring method).
The original validation of the scale by Katzman et al. [1] suggested a score of 6 points or less to be a normal score, with scores of 7 or higher warranting further investigation to rule out a dementia-related disorder. However, based on the clinical research findings of Morris et al. [4], more specific criteria may be given, namely:
Score 0–4: Normal cognition
Score 5–9: Questionable impairment
Score ≥10: Impairment consistent with dementia (evaluate further).
Other sources, such as online software used in primary care settings in the UK (see www.patient.co.uk/doctor/six-item-cognitive-impairment-test-6cit), consider scores of 0–7 normal and ≥8 significant. The exact cutoff used may, obviously (see Chap. 2), influence test metrics [24].
The 6-CIT takes approximately 2 min to complete.
11.3 Diagnostic Utility
Sensitivity of 6CIT was measured by Brook and Bullock [3], who conducted a study to compare the 6CIT, MMSE [5], and the Global Deterioration Scale (GDS) in a sample of 287 community and outpatient participants, comprising 137 controls, 70 with mild dementia (GDS 3–5), and 82 with more severe dementia (GDS 6–7). A sensitivity of around 80 % was reported for the 6CIT, which was considerably higher than that of the MMSE (50–65 %, depending on cut-off). Although the 6CIT scores correlated highly with the MMSE scores, its superior sensitivity led the researchers to conclude that the 6CIT was a better tool for detecting mild dementia [3].
A recent study confirmed the results of Brooke and Bullock [3]. The study, conducted by Upadhyaya et al. [23], compared the performance of the 6CIT with the MMSE in a sample of 209 participants with a mean age of around 79 years. Individuals with and without dementia were retrospectively studied from data provided by an old age psychiatry service. The study reported a sensitivity of 82.5 % and a specificity of 90.9 % at a 6CIT cut-off of 10/11. When the cut-off was lowered to 9/10 the sensitivity of the scale increased to 90.2 % but the corresponding specificity decreased to 83.3 %. When compared with the MMSE, the two scales had a very strong negative correlation (r = −0.822) and the MMSE had a lower sensitivity and specificity of 79.7 % and 86.4 % respectively. When analyzing the Receiver Operating Characteristic (ROC) curves for the MMSE and 6CIT, Upadhyaya et al. also showed superior screening properties of the 6CIT over the MMSE for dementia [23].
In a very similar study into the use of the 6CIT and MMSE, Tuijl et al. asked 253 general hospital patients over the age of 70 years to complete both tests [25]. Similarly to the previous two studies mentioned, a very high negative correlation was found between the 6CIT and MMSE (r = −0.82). This study adjusted the cut-off points in the MMSE for subjects with low (<19/30) and high (<23/30) educational level, comparable with the >11 cut-off on the 6CIT which was not sensitive to educational level. The study found sensitivity and specificity scores of 6CIT to be 0.90 and 0.96 respectively with a positive predictive value of 0.83 and negative predictive value of 0.98. The area under the ROC curve was reported as 0.95. This study, as in previous research, concluded that 6CIT is a suitable screening instrument for cognitive impairment in a general hospital setting owing to its brevity and ease of use for both patients and professionals [25].
The utility of 6CIT in primary care settings was questioned by Hessler et al. [26]. In a population-based prospective trial, primary care practitioners administered 6CIT to nearly 4000 patients at routine examinations over a 2-year period, with incident dementia diagnoses being established at subsequent examination of health insurance records. 6CIT showed low sensitivity for dementia diagnosis (0.49 and 0.32 at 7/8 and 10/11 cutoffs respectively) but high specificity (0.92, 0.98 respectively). The authors concluded that 6CIT was not suited as a routine screening instrument in primary care [26].
Abdel-Aziz and Larner examined 6CIT as a cognitive screening instrument in a dedicated secondary care cognitive disorders clinic [27]. In a cohort of 245 consecutive patients with a dementia prevalence of around 20 %, 6CIT scores were highly negatively correlated with MMSE scores (r = −0.73; t = 13.0, p < 0.001). 6CIT had good sensitivity (0.88) and specificity (0.78) for dementia diagnosis at the specified cut-off of ≤4; MMSE was less sensitive (0.59) but more specific (0.85) at a cutoff of ≤22/30. For the diagnosis of MCI, 6CIT was again more sensitive (0.66; cutoff ≤9) than MMSE (0.51; cutoff ≤25/30) but less specific (0.70 vs 0.75). Area under the receiver operating characteristic (ROC) curve, a measure of diagnostic accuracy, was 0.90 (Fig. 11.1), 0.85, and 0.71 for the diagnosis of dementia vs. no dementia, dementia vs. MCI, and MCI vs. no cognitive impairment respectively. Weighted comparisons showed net benefit for 6CIT compared to MMSE for diagnosis of both dementia and MCI. Effect sizes (Cohen’s d) for 6CIT were large for dementia diagnosis (1.89) and moderate for MCI diagnosis (0.65), again comparable with MMSE (1.34 and 0.70 respectively) [27]. Analyzing the same dataset but using the 6CIT 7/8 cutoff (as per www.patient.co.uk/doctor/six-item-cognitive-impairment-test-6cit) marginally increased sensitivity but reduced specificity for dementia diagnosis [24].
Fig. 11.1
Receiver operating characteristic (ROC) curve for 6CIT for diagnosis of dementia versus no dementia (Based on data from [27])
6CIT has been compared with other cognitive screening instruments using summary or comparative measures. As for MMSE, 6CIT scores are highly negatively correlated with scores on the Mini-Addenbrooke’s Cognitive Examination (M-ACE; see Chap. 6) with r = −0.79 (t = 9.4, p < 0.001), and negatively correlated with scores on the Montreal Cognitive Assessment (MoCA; see Chap 7) with r = −0.54 (t = 2.8, p < 0.02) (Larner, unpublished observations).
The large effect size (Cohen’s d) for 6CIT for dementia diagnosis is similar to a number of other CSIs examined in historical cohorts, including M-ACE, MoCA, Test Your Memory test (TYM; see Chap. 9), and the Addenbrooke’s Cognitive Examination-Revised (ACE-R; see Chap. 6), but the medium effect size for diagnosis of MCI is inferior to that of MoCA and M-ACE [28, 29].
11.4 Advantages and Disadvantages
11.4.1 Time
The 6CIT takes as little as 2 min to complete [23]. This is much shorter than the commonly used MMSE (5–10 min). There are several other brief cognitive tests that can be used as screening instruments for dementia, which, in general, take less time to complete than the MMSE (Table 11.2). The General Practitioner Assessment of Cognition (GPCOG; Chap. 10), Mini-Cog, and Memory Impairment Screen (MIS) are examples of other screening measures used for dementia, all of which have been recommended for use in primary care settings [30]. However Brodaty et al. suggested 5 min for completion of the 6CIT [30]. Even at 2 min, the 6CIT still presents a longer completion time than the Time and Change Test (T&C), the Mental Alternation Test (MAT), the Short Informant Questionnaire on Cognitive Decline in the Elderly (SIQ), and the Ashford Memory Test (AMT), all of which may be administered in 1 min or less.
Table 11.2
Timescales for brief cognitive screening instruments
Task | Time (mins) |
|---|---|
Time and Change Test | 0.4 |
Mental Alternation Test | 0.5 |
Short Informant Questionnaire on Cognitive Decline in the Elderly | 0.5 |
Ashford Memory Test | 1 |
6 Item Cognitive Impairment Test | 2 |
Clock Drawing Test | 2 |
Mini-Cog | 2–4 |
Abbreviated Mental Test
Related posts: The General Practitioner Assessment of Cognition (GPCOG)
The IQCODE: Using Informant Reports to Assess Cognitive Change in the Clinic and in Older Individuals Living in the Community
The Usage of Cognitive Screening Instruments: Test Characteristics and Suspected Diagnosis
 Assessment of the Utility of Cognitive Screening Instruments
 Montreal Cognitive Assessment (MoCA): Concept and Clinical Review
 The Quick Mild Cognitive Impairment Screen (Qmci)
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