What's New at Tokei: A More Complete Cognitive Screening

When we started Tokei, the screening was simple: three words to remember, a clock to draw. It was based on the Mini-Cog, a tool that primary care doctors have used for years as a quick way to screen for cognitive impairment in a 5-minute visit.

That tool is good — it is short, validated, and works. But it answers only one question: is there evidence of cognitive impairment right now? It leaves out three other questions that any thoughtful clinician would also ask:

• Are any of this person's medications causing or worsening their symptoms?
• Is something treatable, like sleep apnea, contributing?
• Have there been personality or mood changes that could be the first sign of something happening in the brain?

A few weeks ago I sat in on a session at the American Psychiatric Association annual meeting on how dementia diagnosis has changed. The argument of that session — and the new clinical practice guidelines it referenced — is that a complete cognitive evaluation has to ask all four of those questions, not just the first one. So we updated Tokei to do that.

What's new today

The screening now has four parts.

1. A fuller cognitive battery. The Mini-Cog has been replaced with a cognitive battery based on SLUMS, the Saint Louis University Mental Status exam — a public-domain instrument that covers more ground than the Mini-Cog. The battery tests:

• Orientation (day, year, state)
• Word registration and delayed recall (5 words)
• Math reasoning (a small word problem)
• Verbal fluency (typing as many animals as you can in 60 seconds)
• Working memory (saying number sequences backward)
• Visuospatial ability (the clock drawing — still here — plus identifying shapes)
• Story recall (a short story we ask you to remember)

Scores are on a 30-point scale with education-adjusted cutoffs. About 10 minutes total.

2. Medication review. You enter the prescription drugs, over-the-counter medications, and supplements you currently take. We check each one against a list of about 80 medications known to have anticholinergic effects on the brain — and we show you which of yours are on that list and how much each contributes.

If you take Benadryl, ZzzQuil, or Tylenol PM at night, a bladder medication, or an older antidepressant, you may be surprised. Anticholinergic burden is one of the most underappreciated, most reversible contributors to cognitive symptoms in older adults.

3. Sleep apnea screening. Eight quick yes/no questions — the STOP-Bang questionnaire — to estimate your risk of obstructive sleep apnea. Untreated sleep apnea is a common, treatable cause of fatigue, poor concentration, and what feels like memory problems. It is also a significant risk factor for long-term cognitive decline, especially in middle age.

4. Behavioral changes (the MBI-C). A 34-item checklist that screens for new, persistent changes in motivation, mood, impulse control, social behavior, or beliefs — symptoms that can sometimes precede memory complaints in dementia. You can complete it for yourself, or a family member can complete it about a loved one.

You'll see all four sections in your results, with the raw scores, a plain-language explanation, and a "discuss with your doctor" pointer where appropriate.

Why we made these specific additions

Two of these four parts — the medication review and the sleep apnea screen — exist because the most common reversible causes of cognitive symptoms are not captured by any cognitive test. A patient can score perfectly on the Mini-Cog and still be quietly cognitively impaired because of nightly Benadryl. A patient can score badly on the Mini-Cog and the cause can be a treatable sleep disorder. A good screening tool should at least raise these questions, not just measure the result.

The MBI-C exists because the field's understanding of how dementia begins is changing. We used to assume that memory problems came first, with behavior changing later as the disease progressed. The data now shows that for many people — especially those whose dementia involves frontotemporal pathology, Lewy bodies, or vascular disease — behavior changes come first, sometimes years before any measurable memory problem. The 2024 revised Alzheimer's diagnostic criteria treat persistent unexplained mood and motivation changes in older adults as a transitional stage of the disease. We should be screening for them. Now we do.

The SLUMS-based cognitive battery exists because the Mini-Cog is too brief to characterize what's happening when there is something happening. It can tell you "something is off" or "looks fine." A fuller battery can tell you which cognitive domains are affected — and that pattern is often the first clue about why. Memory-only problems look different from problems in executive function, which look different from language problems. Different patterns suggest different diseases.

What's still the same

• The clock drawing is still there. It is the test we're named after for a reason: it is one of the simplest, most informative tests in cognitive medicine, and our AI-assisted scoring of it has gotten better over the past year.
• You still get a personal results email.
• It's still free.
• It is still not a diagnosis. This is a screening tool — a way to organize information and to flag things worth bringing to a clinician. It does not replace a clinical evaluation.

What's coming

This is Phase A of a larger reorganization. Two things we're working on next:

• A way to upload your recent lab results (B12, thyroid, basic metabolic panel) so the screening can flag laboratory abnormalities that contribute to cognitive symptoms. These are part of the "Tier 1" workup recommended by the 2025 DETeCD-ADRD clinical practice guideline.
• Better follow-up resources — guidance on what to do with each kind of flag, written in plain language, including how to talk with your doctor about a medication change or a sleep study.

A note on privacy: nothing about your screening is sold or shared with advertisers. The current scope is non-clinical screening only; this is not a substitute for medical care.

If you've taken the screening before, you're welcome to take it again. If you're new — start here.