SLUMS Test: Inability to Spell "World" Backwards
Inability to spell "world" backwards on the SLUMS test indicates impairment in attention and concentration, contributing to a lower total score that may suggest cognitive impairment ranging from mild cognitive impairment (MCI) to dementia, depending on the patient's education level and overall performance.
What the SLUMS Test Measures
The SLUMS (Saint Louis University Mental Status Examination) is a multidomain cognitive screening tool that assesses multiple cognitive functions including 1:
- Attention and concentration (which includes the "world" backwards task)
- Memory (learning and recall)
- Orientation to time and space
- Executive functions
- Language skills
- Visuospatial abilities
The test takes 7-10 minutes to administer and scores range from 0-30 points, with higher scores indicating better cognitive performance 1, 2.
Interpreting Failure on the "World" Backwards Task
When a patient cannot spell "world" backwards, this specifically reflects impairment in attention and concentration domains 2. This single task failure does not diagnose dementia by itself, but contributes to the overall SLUMS score interpretation 1.
Scoring Context
The SLUMS total score must be interpreted based on education level 1:
- For patients with high school education or less: Scores of 20-27 suggest MCI; scores ≤19 suggest dementia
- For patients with more than high school education: Scores of 21-26 suggest MCI; scores ≤20 suggest dementia
Clinical Significance and Next Steps
Any abnormal SLUMS score warrants further comprehensive evaluation 1. The Mayo Clinic guidelines specify that abnormal cognitive screening must be followed by 1:
- Neurologic examination
- Additional multidomain mental status testing
- Appropriate laboratory studies
- Brain imaging studies
Critical Differential Considerations
Before attributing poor performance to dementia, clinicians must actively exclude 1:
- Delirium (use Confusion Assessment Method if suspected, particularly in hospitalized or long-term care patients)
- Depression (screen with PHQ-2, then PHQ-9 if positive; note that PHQ-9 loses accuracy in patients with existing cognitive impairment)
Common Pitfalls to Avoid
Do not use the SLUMS or any cognitive screening tool in isolation to diagnose neurocognitive disorders 1. Performance on mental status tests alone cannot substantiate a diagnosis but indicates whether further evaluation is warranted 1.
Patient characteristics that affect test performance and must be considered include 1:
- Native language
- Education level
- Age
- Cultural background
The SLUMS was developed primarily in VA populations but is validated for broader use 1. It is particularly suited for detecting both MCI and dementia and can track progression through moderate stages of dementia 1.