the MOST®

The Memory Orientation Screening Test (the MOST®) is a short, easy to administer, highly reliable, and valid measure of cognitive functioning for patients.




Rapid, Accurate, Reliable

The Memory Orientation Screening Test (the MOST®) is a well-developed, extensively researched, often used, but not well-known measure of cognition that can be the brief go-to test of cognitive status across many different settings. The MOST correlates very highly with 4-hour batteries of neuropsychological tests involving measures of intelligence, attention, memory and executive function.

The MOST accurately identifies Mild Cognitive Impairment (MCI) and dementia, separating them efficiently from cognition that is normal for age.

The MOST is highly reliable and reflects stability or change in cognition over time.

The MOST is easy to use, well-accepted by patients at all levels of cognition, easily translated into foreign languages, uses universal stimuli, and can be administered electronically in person or over digital media.

Simply put, it is the MOST®.

The MOST® BASICS

Composed of 4 elements:

M emory for three words
O rientation to date and time
S equential recall of 12 pictured household objects
T ime organization and hand setting on a predrawn clock (optional animal naming)

  • – Five minutes to administer and score
  • – 0-29 point scale, higher scores reflecting better cognition
  • – Hand or computer administration and scoring
  • – In person or over digital media
  • – Generates a professional report for diagnosis and care
  • – Level of cognition: normal vs. MCI vs. mild/moderate/severe dementia
  • – Subsequent diagnostic steps to pursue
  • – Labs, Scans, PSG, other tests or referrals
  • – Medications to consider
  • – Lifestyle interventions to consider
  • – Generates a patient/family report, in accessible language and action steps
  • – Modifiable for applied settings or research


The MOST® Key Features

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<strong>Brief administration: </strong>
Administered and scored in five minutes or less, on paper or using the iPAD, in approximately half the time of the MMSE.
<strong>High patient tolerance:</strong>
More than 90% of dementia patients complete the MOST. Patients who are blind are not able to identify the visual stimuli or complete the clock drawing test.
<strong>Easy to learn: </strong>
All levels of provders are capable of using the MOST with patients at all levels of cognitive ability in a variety of settings. Medical assistants, administrative staff, physicians and extenders, nurses, psychologists, and respiratory, physical, occupational, speech therapists and clinicians at other levels of training are successfully trained in less than one hour.
<strong>Excellent scoring reliability:</strong>
Correlations between raters exceed r =.90, allowing for confidence in accuracy of score.
<strong>Stable scores across time:</strong>
Test-retest reliability r=.90 for dementia patients over 2 month period and 9 month intervals.
<strong>High correlation with accepted standards:</strong>
MOST correlates r=.81 with MMSE, indicating 64% shared variance and reflecting a shared common construct of dementia. Yet, this correlation is low enough to reflect the unique contribution of the MOST. In addition, the MOST correlates highly with six standardized neuropsychological tests of memory and executive functioning.
<strong>High correlation with dementia severity:</strong>
MOST correlates r=.80 with severity of cognitive impairment.
<strong>Outperforms other tests: </strong>
The MOST has a significantly higher correlation with dementia severity and with standardized memory tests than either the Mini Mental State Exam or the Mini-Cog.
<strong>High sensitivity and specificity: </strong>
ROC demonstrates statistically significant superiority of MOST relative to both MMSE and Mini-Cog (see figure below). It has a sensitivity of 85-89% and a specificity of 76-87%, correctly classifying 83-89% of patients. These levels are significantly higher than either of the other instruments. In addition, when patients with moderate to severe dementia are removed from the evaluation because obviously advanced dementia does not require screening, the MOST is twice as effective than the MMSE in identifying patients who are experiencing dementia. This target population of patients deserves increased attention and initiation of treatment.
<strong>Useful:</strong>
The MOST quickly and reliably identifies patients with MCI or dementia, improves case finding and accuracy of billing for case complexity and allows providers and researchers to track disease severity over time, . The MOST satisfies meaningful use compliance in the Annual Wellness Visit, Welcome to Medicare visits, and, problem-focused visits in primary care, as well as meeting the specific concerns for cognitive assessment and treatment in orthopedics, cardiac surgery, urology, psychiatry, and, sleep medicine,. Specialized applications for rehabilitation and pharmaceutical research are available.
<strong>International and cultural neutrality: </strong>
The MOST has been translated into Spanish. We are presently inviting partners to participate in validation studies in Europe, South America and Asia. The MOST was specifically designed for low cultural loading.
<strong>Availability: </strong>
The MOST is now available in paper-format, and on the iPAD through the App Store or on iTunes. Quantity pricing is available. Contract pricing is offered to large medical groups, hospital systems, pharmaceutical companies, home health agencies, benefits management and insurance companies.
<strong>Support: </strong>
Training and support is available through Internet contact, via telephone conference and Powerpoint presentations. On-site training and train-the-trainer packages are available. Corporate contracts are application dependent.

Distilling It All Down

When 15 standardized neuropsychological tests are distilled down with clinical experience and research the end result is the essence of all neuropsychological testing, The Memory Orientation Screening Test (the MOST®).


Concentrated:

3½ hours of testing in five minutes

Powerful:

r >.80 with dementia severity 88% sensitivity, 83% specificity

Stable:

r >.90 over one year

Portable:

iPad app

Easy to use:

From test to report in minutes No special training required

Accurate. Versatile. Economical.

PUBLISHED STUDIES: ACCURACY and RELIABILITY of the MOST®


2010

Development and validation study: Demonstrated brevity, accuracy, and comparative advantage over existing brief screening tests on a sample of 1752 memory clinic patients. 1

Results: The MOST was significantly more sensitive than MMSE or Mini-Cog, twice as accurate as MMSE for identifying mild dementia, better correlated with standardized memory tests, more reliable over time, and minimally related to depression.

Conclusions: The MOST is routinely administered in less than 5 minutes by a medical assistant, more accurately identifies dementia and severity than current screening tests, and emulates longer memory testing, making it valuable for Annual Wellness Visits and many applied clinical settings.


2011

The MOST showed very high (r = .86) correlation with dementia severity and outperformed MMSE, patient and family ratings on sample of 201 patients. 2

Abstract conclusion: This study found that patients, family members, and even physicians have trouble detecting cognitive impairment. A better bet: Routinely administer an objective cognition test.


2013

The MOST showed 80% correct diagnostic classification on US population prevalence-stratified (normal vs MCI vs dementia) sample of 217 elders. 3

Results: The MOST correlated highly with diagnostic severity and each neuropsychological test, demonstrating 80% correct diagnostic classification. The MOST showed a stronger relationship with dementia severity and list memory than MMSE. MOST cutting scores provided 88% sensitivity and 83% specificity for identifying MCI and dementia, yielding a PPV of .72 and NPV of .93.

Conclusion: The MOST accurately classifies patients from a diagnostically proportioned sample as normal, MCI, or demented and has high sensitivity and specificity for separating normal from impaired. Providers can use this 5-minute test to accurately identify cognitively impaired patients and to reassure elders with normal cognition, while acknowledging that no single test is adequate for making a definitive diagnosis.


2014

The MOST paper and iPad versions showed high equivalency and accuracy of diagnosis on 98 consecutive NP patients. Found no 1-hour repeat test practice effect. 4

Abstract conclusions: ANOVA showed no significant difference between versions or presentation order. Both versions correlated very highly with cognitive level and neuropsychological endpoints, confirming previous research. The MOST-96120 is a computerized neuropsychological assessment device that demonstrates equivalence with its paper-based original, allowing for confident reliance on the findings of previous research.

HISTORY

2007
2007

theMOST™ was initially developed as paper-based in 2007. Developed to fill the gap between subjective patient complaints and 4-hour detailed neuropsychological evaluation. Created by Mitchell Clionsky, Ph.D., ABPP-CN and Emily Clionsky, MD in partnership as Clionsky Neuro Systems, Inc.

2012
2012
2012

Released on iPad as MOST™, an unlimited use version and as MOST-96120, a per-use version meeting requirements for CPT reimbursable code 96120.

2013
2013
2013

Developed and distributed version mdMOST™ in partnership with Lincare, Inc. Distribution ceased in 2016 when CMS eliminated reimbursable CPT code for computerized testing by MD.

2014
2014
2014

Sold MOST-96120 to Quest Diagnostics.

2016
2016
2016

Quest rebranded as CogniSense™ and released on proprietary platform.

2022
2022

Quest relinquished rights of theMOST™ to CNS (Clionsky Neuro Systems, Inc.).

2023
2023

Clionsky Neuro Systems, Inc. plans to update and redeploy with ISO investors and corporate partners.


The Future of the MOST®

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Health Care Professional (HCP) use
  • The Most HCPs fail to make an MCI or dementia diagnosis early in the course of the illness. They rely on patient or family complaint, which is unreliable. Survey data finds that 40% of health care professionals are uncomfortable making the diagnosis.
  • However, early diagnosis while the patient is still in the Mild Cognitive Impairment and Mild Dementia stage has become increasingly important with the FDA approval of aducanumab and lecanemab, as well as the likely approval of donanemab and other new treatments.
  • HCP’s need a brief but accurate measure for identifying patients while they can be most effectively treated.
  • As our research shows, the MOST is more sensitive than the MMSE, which takes more than twice as long to administer and score (12 minutes), is cumbersome, and must be purchased. The other primary competitor, the Montreal Cognitive Assessment (MoCA), is more accurate than MMSE and is likely equivalent to the MOST, but takes 15 or more minutes to administer.
  • The MOST could be deployed to HCPs economically and could become a standard in the industry. Using a more “plain vanilla” computer code, it could be administered over a number of different platforms. The introduction of Artificial Intelligence voice recognition also creates opportunity for easier administration and scoring in the clinical office, further freeing HCPs for other clinical tasks.
Minute Clinics and Telemedicine
  • Minute Clinics and similar nurse practitioner-based diagnostic centers could assess cognition and develop a revenue stream by embedding the MOST into a 16-minute assessment, reimbursable under existing CPT codes for neuropsychological assessment. This new “MOST Suite 16” uses the existing MOST, but adds a delayed recall score, additional learning and recall scores from The Shopping List Test (our
    proprietary test of memory), and a public domain measure of executive function to increase the granularity and breadth of data while providing a billable and reimbursable service.
  • Telemedicine services such as Teladoc can also incorporate the MOST as part of a clinical assessment of cognition designed for patients who cannot travel or who may need an in-home cognitive test as part of a broader assessment. Since the COVID close and subsequent reopening of our practice two months later, we have been routinely using in-office zoom technology to replace the face-to-face administration
    historically used in neuropsychology. We are able to administer the MOST reliably and accurately by screen sharing our stimuli.
Home Use: The Family MOST
  • Child, sibling or spouse caregivers are often concerned about the cognition of a loved one. They are often stymied by the reticence of HCPs to test for cognition, the lack of available neuropsychological services, or the resistance of the family member to be tested by someone outside of the family.
  • Using a computer delivered MOST, with video interface and assistive scoring, a competent relative could administer the MOST, input the basic scores into an onscreen program, and receive a detailed report with recommendations. If desired, a more detailed questionnaire could be completed by the family and reviewed by a neuropsychological professional. If scores are concerning, the report could be taken by the family to their HCP or sent directly, with patient permission, to the treating professional, who could then examine the patient, repeat the MOST or another test, and begin the full diagnostic and treatment process.
Future Research Use
  • The MMSE has been used as a gross screening data point for entry into new studies for Alzheimer’s medications. As are research has repeatedly demonstrated, the MMSE is insensitive for higher functioning patients. As such, many who would qualify for such pharmaceutical studies and could potentially gain the most advantage, are systematically excluded because their MMSE scores are “too good.” Using the MOST as the entry point, more early stage patients would pass initial test entry protocols. In addition, the excellent test-retest reliability and absence of practice effect makes the MOST a good basic indicator of change over time. The MOST has been used by us in a 2-year study presented at the 2014 American Academy of Neurology 5 and in a study on MCI and hearing acuity. 6
  • The MOST has been used by The Arbors, a privately held group of assisted living centers in Massachusetts as an entry point cognitive measure to help determine level of assistance. It has also been considered as a cognitive measure for home health agencies when determining needs and resources in home evaluations.
  • Mental health conditions, such as schizophrenia and bipolar disorder, medical conditions such as sleep apnea and diabetes, and drug and alcohol abuse syndromes, as well as types of dementia other than Alzheimer’s negatively impact short-term memory and executive functions. The MOST is a general tool of cognitive level that can be applied to any of these conditions, with known standard errors of measurement that can be used to gauge change over time.

Are you interested in the MOST®?

Yes, I am a corporation that is interested in partnering with CNS regarding the MOST.
Please contact us to discuss possible partnership opportunities.

1 Clionsky, M and Clionsky, E, “Development and Validation of the Memory Orientation Screening Test, American Journal of Alzheimer’s Disease and Other Dementias, 2010, 25 (8), 650-656. doi: 10.1177/1533317510386216

2 Clionsky, M and Clionsky, E, “Identifying Cognitive Impairment in the Annual Wellness Visit: Who Can You Trust?” Journal of Family Practice, 2011, 60: 653-659.

3 Clionsky, M and Clionsky, E, “The Memory Orientation Screening Test (MOST) accurately separates normal from MCI and demented elders in a prevalence-stratified sample, Journal of Alzheimer’s Disease and Parkinsonism, 2013, 3:1, http://dx.doi.org/10.4172/2161-0460.1000109

4 Clionsky, M and Clionsky, E, “Psychometric Equivalence of a Paper-Based and Computerized (iPad) Version of The Memory Orientation Screening Test (MOST), The Clinical Neuropsychologist, 2014,
http://dx.doi.org/10.1080/13854046.2014.913686