Cognitive impairment is a comorbidity that occurs in response to a complex interplay of systemic factors, resulting in heightened vulnerability to adverse health outcomes.1 Deficits in cognition, specifically in attention, memory, and executive function, are highly prevalent in chronic lung disease, with a prevalence between 25% to 75% among COPD patients.1 Cognitive dysfunction is gaining increasing recognition in chronic lung disease as it can impair an individual’s ability to manage complex therapeutic regimens, increases the risk of hospitalizations, and is associated with worse health-related quality of life.2 Furthermore, symptoms such as dyspnea can impose an additional "cognitive load", limiting functional performance during activities of daily living.3 Unfortunately, many have had limited use in PR.
No single best method currently exists to assess the full spectrum of cognitive function in this population. Shorter screening tools and digital batteries are increasingly utilized to detect deficits in processing speed, psychomotor sequencing, and working memory.
The following instruments are described:
- Digit Span Test
- Digit Symbol Test
- Digit Vigilance Test
- Finger Tapping Test
- Mini-Mental State Examination (MMSE)
- Montreal Cognitive Assessment (MoCA)
- Rey Auditory Verbal Learning Test (RAVLT)
- Trail Making Test (TMT)
We thank the following who collated this material: Alessandra Adami PhD, Department of Kinesiology, College of Health Sciences, University of Rhode Island, Kingston, RI, US; Peter Rassam, University Health Network, Toronto, Canada; Darlene Reid, PhD University of Toronto, Toronto, Canada; Dmitry Rozenberg, MD, PhD (Lead) University Health Network, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; W. Ali A. Salman Al-Timimi, University Health Network, Toronto, Canada; Suzanne Lareau, MS, RN (Co-Ed) (University of Colorado, Denver, US) Clarice Tang PhD (Co-Ed), Victoria University, Melbourne, Australia.
References:
- Ranzini L, et al. Front Psychol 2020; 11:337.
- Chang SS, et al. J Am Geriatr Soc 2012; 60:1839-1846.3 Rozenberg D, et al. Chest 2024; 166:721-732.
PRA OUTCOMES
Wechsler Adult Intelligence Scale - Digit Span Test
Description | |
| Name of Questionnaire | Wechsler Adult Intelligence Scale (WAIS) – Digit Span Test |
| Abbreviation/Alternate Name | WAIS-IV Digit Span; WMI (Working Memory Index) |
| Description: | Cognitive test (part of WAIS) of working memory. 1 |
| Developer | David Wechsler (Original, 1955). 1 Pearson Clinical (Current). |
| https://www.pearsonassessments.com/en-us/Store/Professional-Assessments/Cognition-%26-Neuro/Wechsler-Adult-Intelligence-Scale-%7C-Fourth-Edition/p/100000392 (Publisher) | |
| Cost | Part of WAIS-IV Kit. Record forms sold separately (~$200 for 25). |
| License required | Copyright © 2008 NCS Pearson, Inc. |
| Self-or rater-administered | Rater-administered |
| Time to complete | 5–10 minutes |
| Number of items | Pairs of trials increasing in length from 2 to 9 digits. |
| Domains & categories (#) | 3 (WAIS-IV version). |
| Name of domains/ categories | Digit Span Forward (DSF), Digit Span Backward (DSB), Digit Span Sequencing (DSS).2 |
| Scaling of items | 1 point/correct response.3 |
| Scoring | Total Raw Score: Sum of correct trials for Forward, Backward, and Sequencing (Max 48 in WAIS-IV).3 |
| Test-retest/ reproducibility | Test-rest reliability in healthy adults (0.70 to 0.80).3 |
| Validity | DSS may potentially be a more sensitive measure of working memory capacity than DSF.2 |
| Responsiveness to PR | DSF: pre-post mean D = 0.06 (in male COPD patients) and 0.79 (in female COPD patients). DSB: pre-post mean D = - 0.36 (in male COPD patients) and 0.67 (in female COPD patients) (p > 0.05).4 |
| MID | Not established for pulmonary diseases. |
| Languages | Available in several languages. |
| References | 1. Wechsler, David (1939). The Measurement of Adult Intelligence. Baltimore (MD): Williams & Witkins. 2. Egeland J et al. Appl Neuropsychol Adult. 2026; 33(1); 65-72. 3. Stafford C & Bennett R. Digit Span. In: Clinical Integration of Neuropsychological Test Results. 1 st ed. CRC Press. 2024. 4. Emery CF et al. Chest. 1991;100:613-7. |
| Date of most recent updates | January 2026 |
PRA OUTCOMES
Wechsler Adult Intelligence Scale - Digit Symbol
Description | |
| Name of Questionnaire | Wechsler Adult Intelligence Scale (WAIS)© - Digit Symbol |
| Abbreviation/Alternate Name | WAIS-IV Coding; Digit Symbol Substitution Test (DSST); Digit Symbol |
| Description: | A test that assesses psychomotor speed and visual-motor coordination. 1 |
| Developer | David Wechsler (Original, 1955) 1 Pearson Clinical (Current). |
| https://www.pearsonassessments.com/en-us/Store/Professional-Assessments/Cognition-%26-Neuro/Wechsler-Adult-Intelligence-Scale-%7C-Fourth-Edition/p/100000392 (Publisher) | |
| Cost | Part of WAIS-IV Kit. Record forms sold separately (~$200 for 25). |
| License required | Copyright © 2008 NCS Pearson, Inc. |
| Self-or rater-administered | Rater-administered. |
| Time to complete | 90 to 120 seconds. |
| Number of items | 135 items (WAIS-IV version). |
| Domains & categories (#) | 1 |
| Name of domains/categories | Coding (Part of Processing Speed Subset) |
| Scaling of items | Numbers (1–9) are paired with unique symbols. Participants match symbols to their corresponding number within the time limit.21 point for each correctly drawn symbol within the time limit. |
| Scoring | Raw score (0–135) converted to Scaled Score (1-19). 2 |
| Test-retest/ reproducibility | Test-retest reliability > 0.80 in clinical adult populations2 |
| Validity | Coding (WAIS-IV) shown to have moderate-to-strong correlation with other processing speed subtests.2 |
| Responsiveness to PR | Pre-post mean D = 5.62 male COPD patients and 6.61 female (p < 0.05).3 |
| MID | Not established for pulmonary diseases. |
| Languages | Available in several languages. |
| References | 1. Wechsler, David (1939). The Measurement of Adult Intelligence. Baltimore (MD): Williams & Witkins. 2. Arnold M. Coding. In: Clinical Integration of Neuropsychological Test Results. 1 st ed. CRC Press. 2024. 3. Emery CF et al. Chest. 1991;100:613-7. |
| Date of most recent updates | January 2026 |
PRA OUTCOMES
Digit Vigilance Test
Description | |
| Name of Questionnaire | Digit Vigilance Test |
| Abbreviation/Alternate Name | DVT; Lewis DVT |
| Description: | Assesses sustained attention (vigilance) and psychomotor speed by asking participants to scan two pages of random numbers and cross out all 6s and 9s as quickly and accurately as possible. 1 |
| Developer | Ronald F. Lewis (1995). |
| https://www.parinc.com/products/DVT (Publisher) | |
| Cost | ~$200 USD for a kit (Manual + 25 Test Booklets). |
| License required | Copyright © 1995 Psychological Assessment Resources (PAR). |
| Self-or rater-administered | Rater-administered. |
| Time to complete | 10 minutes. |
| Number of items | 59 rows of digits |
| Domains & categories (#) | 2 |
| Name of domains/ categories | Total Time (Psychomotor Speed), Accuracy (Errors of Omission & Commission) |
| Scaling of items | Raw values (errors and total time) compared to normative data for age, education and socioeconomic status |
| Scoring | Total Time: Seconds to complete. Errors: Count of missed targets (Omissions) or wrong targets (Commissions). 2 |
| Test-retest/ reproducibility | Test-retest reliability in young adults r= .91. 2 |
| Validity | DVT total errors correlate with Discriminant Reaction Time Test (r = .503); total time =ns. 2 |
| Responsiveness to PR | Pre-post mean D = 2.6 in COPD patients. 3 |
| MID | Not established for pulmonary diseases. |
| Languages | Available in several languages. |
| References | 1. Lewis RF. Digit vigilance test. Odessa, FL: Psychological Assessment Resources; 1995. 2. Kelland DZ & Lewis RF. Arch Clin Neuropsychol. 1996;11: 339-344. 3. Emery CF et al. Health Psychol. 1998;17:232-240. |
| Date of most recent updates | January 2026 |
PRA OUTCOMES
Finger Tapping Test
Description | |
| Name of Questionnaire | Finger Tapping Test |
| Abbreviation/Alternate Name | FTT; Finger Oscillation Test; Halstead Finger Tapping Test |
| Description: | Measure of psychomotor speed and motor function by index finger tapping on an apparatus as rapidly as possible for 10-second intervals. |
| Developer | Halstead (1947); Reitan (1969). |
| https://neuropsych.com/product/finger-tapping-test-adults-older-children/ | |
| Cost | ~$425 USD |
| License required | No |
| Self-or rater-administered | Rater-administered |
| Time to complete | 5-15 minutes |
| Number of items | 5 consecutive 10-second trials per hand (Total 10 recorded trials). |
| Domains & categories (#) | 2 |
| Name of domains/ categories | Dominant and non-dominant hand motor speed. |
| Scaling of items | Count of taps per 10-second interval. 2 |
| Scoring | Average number of taps across 5 consecutive trials for each hand . 2 |
| Test-retest/ reproducibility | Test-retest (young healthy adults):
|
| Validity | Correlates with Purdue peg placement in adults (r = 0.78). 2 |
| Responsiveness to PR | Dominant hand: pre-post D = 2.05 (in male COPD patients) and 3.61 (in female COPD patients) Non-dominant hand: pre-post D = 1.45 (males with COPD) and 0.22 (in females) p < 0.05. 4 |
| MID | Not established for pulmonary diseases. |
| Languages | Available in several languages. |
| References | 1. Cousins MS et al. Pharm Biochem Behm 1998; 59:445-449. 2. Castro K. Finger Tapping Test (FTT). In: Clinical Integration of Neuropsychological Test Results. 1 st ed. CRC Press. 2024. 3. Morrison MW et al. Percept Mot Skills. 1979; 48:139-142. 4. Emery CF et al. Chest .1991; 100:613-7. |
| Date of most recent updates | January 2026 |
PRA OUTCOMES
Mini-Mental State Examination
Description | |
| Name of Questionnaire | Mini-Mental State Examination |
| Abbreviation/Alternate Name | MMSE; MMSE-2 (2 nd edition); Folstein Test |
| Description: | Screening tool for cognitive impairment. |
| Developer | MF Folstein 1 |
| copyright@parinc.com | |
| Cost | $119.00 (50 Test Forms), PAR, Inc. |
| License required | Copyright https://www.parinc.com/products/MMSE |
| Self-or rater-administered | Rater-administered |
| Time to complete | 10-15 minutes; 5 minutes to score. |
| Number of items | 11 |
| Domains & categories (#) | 6 |
| Name of domains/ categories | Orientation, Registration, Attention & Calculation, Recall, Language, and Visuospatial. |
| Scaling of items | Orientation (0-10), Registration (0-3), Attention and Calculation (0-5), Recall (0-3), Language (0-8), Visuospatial (0-1) |
| Scoring | Higher score reflects better cognitive function (0-30) · 24-30 No impairment · 18-23 Mild · 0-17 Severe 2 |
| Test-retest/ reproducibility | Internal consistency: Cronbach’s a = 0.68-0.96 2 Test-Retest Reliability: r = 0.68 to 0.95 2 |
| Validity | Lower validity than MoCA for detecting mild cognitive impairment in COPD. 3 |
| Responsiveness to PR | Mean change using standardized MMSE in COPD: - without cognitive impairment: D 0.5 ± 1.2 (p <0.05). 4 - with cognitive impairment: D 0.7 ± 1.1 (p <0.05). 4 |
| MID | Not available in pulmonary diseases. |
| Languages | >70 Translations (https://www.parinc.com/products/MMSE) |
| References | 1. Folstein MF et al. J Psychiatr Res. 1975; 12:189-98. 2. Tombaugh TN & McIntyre NJ. J Am Geriatr Soc. 1992; 40:922-35. 3. Villeneuve S et al. Chest. 2012; 142:1516-1523. 4. Andrianopoulos V et al. Respir Med. 2021; 185:106478. |
| Date of most recent changes | January 2026 |
Montreal Cognitive Assessment
Description | |
| Name of Questionnaire | Montreal Cognitive Assessment 1 |
| Abbreviation/Alternate Name | MoCA© |
| Description: | Early detection of mild cognitive impairment (MCI) |
| Developer | Ziad Nasreddine https://mocacognition.com |
| info@mocacognition.com | |
| Cost | Training certification US $150.00 if not students, faculty members, academic researchers and publicly operated healthcare institutions. Free after certification/signing disclaimer. |
| License required | Training & certification mandatory for “all clinicians, researchers, health professionals, and workers administering MoCA for clinical or research purposes”. |
| Self-or rater-administered | Self and trained by interviewer in person or by telephone.2 |
| Time to complete | 5 min telephone to 15 min (paper version). |
| Number of items | 30 |
| Domains & categories (#) | 6 |
| Name of domains/ categories | Attention, orientation, language, verbal memory, visuospatial, and executive function. |
| Scaling of items | 0 to 6 points |
| Scoring | 0-30 (high scores more favorable). Total score and subscores on each of 6 domains: >26; normal; 18–25 mild; 10–17 moderate; <10 severe cognitive impairment 1 |
| Test-retest/ reproducibility |
|
| Validity | Content validity vs. MMSE 1,2 |
| Responsiveness to PR | · 3 months post PR, Pre 22, post 25 p<.01 3 · Those with mild CI and ECOPD 6 wk PR (Δ1.6 ± 2.4, p = 0.004), no change in those without CI 4 |
| MID | Not available in pulmonary disease |
| Languages | >100 (https://mocacognition.com) |
| References | 1. Nasreddine et. al. J Am Geriatr Soc 2005; 53: 695-699. 2. Eastus et al. Front Rehabil Sci 2022; 3: 987356. 3. Bonnevie et. al. Int J Chronic Obstruct Pulmon Dis 2020; 15: 1111-1121 4. Frances et. al. Respir Med 2021; 176: 106249. |
| Date of most recent changes | January 2026 |
Rey Auditory Verbal Learning Test
Description | |
| Name of Questionnaire | Rey Auditory Verbal Learning Test |
| Abbreviation/Alternate Name | RAVLT™; Rey AVLT; AVLT |
| Description: | Assesses verbal learning, immediate recall, delayed recall, and recognition memory. Evaluates episodic memory and susceptibility to interference. 1,2,3 |
| Developer | André Rey (Original, 1958). Adapted by Michael Schmidt (1996). |
| https://www.wpspublish.com/ravlt-rey-auditory-verbal-learning-test (Publisher) | |
| Cost | Fees apply for commercial kits (manuals/forms). Word lists often found in public domain for research, but standardized norms/forms require purchase. |
| License required | Copyright © 1996 by Western Psychological Services. |
| Self-or rater-administered | Rater-administered. |
| Time to complete | 10–15 minutes (active testing). Total time ~45 mins including delay interval.4 |
| Number of items | 30 words total (15 words in List A + 15 words in List B). |
| Domains & categories (#) | 5 |
| Name of domains/ categories | Learning (List A Trials 1–5); Interference (List B); Immediate Recall (List A Trial 6); Delayed Recall (List A Trial 7); Recognition (List A). |
| Scaling of items | 0-15/trial |
| Scoring | Number of correct words.4,5 |
| Test-retest/ reproducibility | Test-retest total learning recall (Trials 1-5, r= 0.68). Internal consistency Cronbach a = 0.80 in young healthy adults.6 |
| Validity | RAVLT learning (i.e., sum of first 5 trials) correlates with Benton Visual Retention Test (BVRT) immediate recall (r = 0.44, p < 0.01). RAVLT delayed recall correlates with BVRT delayed recall (r = 0.39, p < 0.05).6 |
| Responsiveness to PR | 3-months PR: RAVLT sum of first 5 trials: = 6.23, 95% CI [3.24, 9.23] RAVLT immediate recall: = 1.14, 95% CI [0.34, 1.94] RAVLT delayed recall: = 1.11, 95% CI [0.16, 2.07]7 |
| MID | Not established for pulmonary diseases. |
| Languages | Available in several languages. |
| References | 1. Rosenberg SJ et al. J Clin Psychol. 1984;40:785-787. 2. Loring DW et al. J Int Neuropsychol Soc. 2023;29:397-405. 3. McMinn et al. Clin Neuropsychol. 1988;2:67-87. 4. UDS Instructions Form C2T. Univ of Washington; 2025;30-31. 5. Stricker et al. J Int Neuropsychol Soc. 2020;27;211-226. 6. Magalhaes SDS et al. Clin Neuropsych. 2012;9:129-137. 7. Pereira ED et al. Lung. 2011;189:279-285. |
| Date of most recent updates | January 2026 |
Trail Making Test
Description | |
| Name of Questionnaire | Trail Making Test 1 |
| Abbreviation/Alternate Name | TMT |
| Description: | A test to assess cognitive function (psychomotor speed, visual attention, working memory, executive function). Trail A and B; are part of the Halstead-Reitan Neuropsychological Battery. |
| Developer | John E. Partington & Russell G. Leiter 1 |
| https://eatspeakthink.com/wp-content/uploads/2018/06/IowaTrailMaking.pdf | |
| Cost | Free. |
| License required | No |
| Self-or rater-administered | Rater-administered. |
| Time to complete | 5 to 10 minutes. |
| Number of items | Part A consists of connecting 25 numbered circles (1 to 25) in ascending order; Part B 25 circles alternating numbers and letters (1 to 13, A to L). |
| Domains & categories (#) | Two. |
| Name of domains/categories | Parts A & Part B. |
| Scaling of items | In seconds |
| Scoring | Number of seconds to complete Part A and Part B. Higher scores indicate greater cognitive impairment. 1 |
| Test-retest/reproducibility | Test-retest reliability:
0.69 (neuropsychiatric patients). 3
0.66 (neuropsychiatric patients). 3 |
| Validity | Construct validity: Part A (visuoperceptual abilities) and Part B (working memory and task-switching). 4 |
| Responsiveness to PR | · Part A: pre-post mean D = -2.17 (in male COPD patients) and -4.02 (in female COPD patients). · Part B: pre-post mean D = -33.89 (in male COPD patients) and -40.4 (in female COPD patients) (p < 0.05). 5 |
| MID | Not available for pulmonary diseases. |
| Languages | Available in several languages. |
| References | 1. Reitan RM.. Percept Mot Skills . 1958;8:271-276.. 2. Matarazzo JD et al. J Nerv Ment Dis. 1974;158:37-49. 3. Goldstein G et al. Clinical Neuropsychol.1989;3:265-272. 4. Sanchez-Cubillo I et al. J Int Neuropsychol Soc. 2009;15:438-50. 5. Emery CF et al. Chest. 1991;100:613-7. |
| Date of most recent changes | January 2026 |