Attention Testing in Mental State Examination

World Reversal Score Serial 7's Score
Enter patient response to WORLD reversal
Patient Score
Indicate start number:80, 90 or 100
First subtraction
Second subtraction
Third subtraction
Fourth subtraction
Fifth subtraction
How to use scoring aid
Enter the letter or letters the patient provides to the request of spelling WORLD backwards (maximum of five letters).
Ignore letters other than W, O, R, L or D. (for example, if the patient states DRLWE, enter DRLW.)
Do not insert any spaces or punctuation between the letters.
Click on "Click to obtain score."
How to use scoring aid
The patient is requested to subtract 7 from 100, and to keep subtracting 7 from the result.
Each result, to a maximum of 5 responses, is scored independently for accuracy.
Enter each result in the appropriate box, and then click on "Click to obtain score."

Attention testing is commonly performed when assessing cognition. Various tests are used such as:
    1. Spelling a five letter word in reverse, such as WORLD
    2. Serial number subtractions (7 from 100, 3 from 20, or counting down from 10)
    3. A test
    4. Digit span forward and backward
    5. Days of week or months of the year, forwards and backwards
    6. Cancellation tests of letter, number or figure
    7. Trail making tests
    8. Stroop test

WORLD reversal (or equivalent word testing) is commonly done as an isolated attention test or as part of a cognitive assessment scale. WORLD reversal scores or serial seven subtractions may contribute 5 of 30 points on some cognitive scales, or 17% of the total (as in the Mini Mental State Examination where either test is scored, or as in the Standardised Mini Mental State Examination (SMMSE) where only WORLD reversal is scored).

There is much confusion about scoring systems, resulting in a significant variance in results, even by experienced testers. This error leads to a potential score difference of up to four points for attention testing. This degree of variation is within the natural annual decline for patients with Alzheimer's disease. This website presents an easy and simple scoring tool (which will thereby produce consistent and reliable scores), and which will support training in scoring two attention tests.

The WORLD reversal scoring system described below is that used at the University of British Columbia (UBC). It provides guidance for all responses, including 6 or more letter responses to WORLD reversal. As it is rare to obtain more than 5 letter responses, the website presents a scoring tool for up to 5 letter responses. Other scoring systems such as the Standardised Mini Mental State (SMMSE) score only the last 5 letters when the patient's response is 6 or more letters. The score for WORLD reversal responses up to 5 letters is the same by either the UBC or SMMSE methods. Check the scoring system used at your institution.

The website could also be used to check word reversal scores in other languages by appropriate substitution of the letters to the equivalent letter position for WORLD.

English W O R L D
French M O N D E
Italian C A R N E
Italian M O N D O
German R A D I O
German P R E I S
Spanish M U N D O

For example, an Italian speaking patient was asked to spell CARNE backwards, and replied EARN. The equivalent WORLD reversal reply is DORL. Enter DORL in the program above and a score of 2 is obtained.

Scoring serial seven subtractions from 100 requires each answer to be scored on its own merit. For example, a response of 93-90-83 scores 2 as the first and last subtractions are correct. The Serial 7's score tool above assists with the scoring of up to five subtractions.

The other attention tests are well described in the literature and can be used at the bedside.

UBC scoring guidelines for WORLD reversal

(My thanks to Dr Lynn Beattie, Medical Director of Clinic for Alzheimer Disease and Related Disorders, UBC Hospital, Vancouver, British Columbia, Canada for permission to publish)

PLEASE: Read instructions carefully to ensure that the patient understands what the question is asking.

Scoring Possibilities

Create 5 spaces to correspond to the proper placement of one of the letters of WORLD. The best way to handle the WORLD question is to write each letter the patient says into the spaces. One letter placed in either the absolute correct position or the relative correct position equals 1 point.

1. In the case of errors in the given five letters:

      Ex: D L O R W

Here, the only problem is that the patient switched the O and the R. In short, one reversal of letters results in 4 points.

This brings up an important point: when looking at positions of letters, use the letters in absolute correct position (here, D, L, W) as points of reference (i.e. find them first, then look at the rest of the letters). The absolute correct position of O means that it occupies the 4th space from the left. Here, O is not in its absolute correct position.

The relative correct position of O means that it lies either after the R or before the W, but not in the correct space (4th from the left). If we choose to look at O first, the O lies before the R, but it is in relative correct position because it remains before the W. If we choose the R to look at first, then R is in relative correct position as it remains after the L, and O is in the wrong place. Either way, the answer shows 3 letters in the absolute correct position and 1 letter in the relative correct position.

     Ex: D R L O W

Here, the same issue is at work, D, O and W are in the absolute correct position, but the R and the L are reversed. The R is normally after the L but before the O. If we choose to look at R first then, R remains before the O and is in the relative correct position and it is the L that is out of place. If we choose to look at the L first, it remains after the D and it is the R that is in the wrong place. Either way, there are 3 letters in the absolute correct position and 1 letter in the relative correct position. This answer merits 4 points (it is another letter reversal).

     Ex: D L D R W

Essentially, ignore the repeated D. This example is similar to the one above, except with the absence of the O, the R is now in the relative correct position. The patient is awarded 4 points.

2. In the case of too few letters:

Award a point for each letter that appears in a correct position. (NB: pay close attention to the relative correct position, as too few letters shifts the letters out of their absolute correct positions ).

     Ex: D R O W _

Here, the patient merely missed the L so they are awarded 4 points. R is in the relative correct position as it appears in front of the O . 4 points can be awarded.

     Ex: D O W _ _

     Ex: D R W _ _

Here, 2 letters are in the relative correct position and the D is in its absolute correct position so 3 points can be awarded. The absence of letters not only shifts the absolute correct position but it also changes the relative correct position. Use D as the reference: The R and the O now occupy a relative correct position as they lie between the D (which remains in its absolute correct position) and the W (shifted out of its absolute correct position).

     Ex: D W L _ _

Here, only one letter is in the relative correct position: the W. The L needs to be in between the other two letters in order to be correct. W is in the relative correct position because it appears behind D, which occupies its absolute correct position. The patient is awarded 2 points.

3. In the case of too many letters: (i.e. six or more) subtract one point per letter of excess. (This situation is not scored by the WORLD Reversal Score Tool above.)

     Ex: D L R O W L

Here, the patient gave an extra letter but they got the backward spelling correct, so their score would be 4 points, one point for each correct letter in the correct place and a deduction of 1 point for the extra letter. In the case of an excess of two letters, subtract two points.

     Ex: D R O L W D L

Here, again there are too many letters, but the backward spelling is incorrect. Essentially, L is in the wrong place but, the first D, the R, the O, and the W are in the correct place. D, and W are in the absolute correct position (1st and 5th from the left), and R and O lie in between the D and W (reference points), so they are in the relative correct position ( L is out of place). The extra D and L account for deductions, so the score here is 2.


This work cannot be reproduced by any person or company without
the written consent of Dr Hetesh Ranchod at the email below.

This website does not promote or sell any cognitive assessment tool,
and should not be confused with any website that performs these activities.
Please forward any comments to Dr Hetesh Ranchod at
free web counter
web counterr
Page design by Dipal Shah and Bhavna Narotam