Research Article
Dement Geriatr Cogn Disord
DOI: 10.1159/000516564

Received: February 25, 2021
Accepted: April 13, 2021
Published online: June 14, 2021

Online Tool (Brain Assessment) for the
Detection of Cognitive Function Changes
during Aging
Masayuki Satoh a Ken-ichi Tabei b Saiko Fujita c Yoshinori Ota caDepartment of Dementia and Neuropsychology, Advanced Institute of Industrial Technology, Tokyo Metropolitan
University, Tokyo, Japan; bSchool of Industrial Technology, Advanced Institute of Industrial Technology, Tokyo
Metropolitan University, Tokyo, Japan; cResearch Institute of Brain Activation, Tokyo, Japan

Abstract
Introduction: It is well-known that cognitive function declines with age. In order to detect changes in cognitive function, cognitive tests should be performed repeatedly. Currently existing cognitive tests come in only a single version,
so the subject is likely to remember the contents with repeated testing. And, under the outbreak of coronavirus disease 2019 (COVID-19), in-person assessment should be
avoided. This study was performed to develop a new cognitive test (brain assessment, BA) that has 5 versions and canbe performed on a personal computer (PC) through the Internet. Materials and Methods: Five thousand subjects performed the online BA, which consisted of 5 subtests: number
memory, word memory, mental rotation test, N-back test,
and judgment test. We standardized the raw scores (cognitive scores, CSs) using mean and standard deviation, whichwere 50 and 10, respectively. Then, we calculated the mean
CS for each sex and age, plotted the relationships between
ages and mean CSs on figures, and calculated the formula ofcognitive changes during normal aging. Results: The CSs of
all subtests decreased with aging. The regression coefficientkarger@karger.com
www.karger.com/dem© 2021 S. Karger AG, Baselwas from −0.31 to −0.45. It is noteworthy that in most subtests, the CSs started to increase at 85 years of age. Discussion: Our BA has 5 versions and can be done on a PC using
the Internet. We tested the BA in a large number of subjects,
and the standard values of CSs were measured in individuals
up to 89 years of age. By performing this test repeatedly, subjects can evaluate the degree of their cognitive decline. If therate of cognitive decline is greater than that predicted using
the normalized formula, the subjects can undertake strategies to improve their control of lifestyle-related diseases orother habits of daily living. Conclusion: The BA can be easily
taken online using a PC, and its scores linearly declined withnormal aging. The BA will be useful for detecting longitudinal cognitive changes and comparing them to the patternseen in normal aging.
© 2021 S. Karger AG, Basel

Introduction

Recent studies have demonstrated that through adequate intervention, including the control of lifestyle parameters, such as those related to hypertension or physical exercise, the occurrence of dementia can be prevented
to some degree. However, the control of disease-related
lifestyle risks has been very poor. For example, adequate
Correspondence to:
Masayuki Satoh, satou-masayuki @ aiit.ac.jp

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Keywords
Cognitive decline · Dementia · Brain assessment · Cognitive
score

Mean
SD

Age

SD
Mean

y = –bx

SDb>aIndication of possible
cognitive impairment in the future

Abnormalay = –ax

Cognitive function

Cognitive functionSDb

Mean score
The score of a subject
SDStandard deviation

Age

Fig. 1. Examples of cognitive tests. a Most cognitive tests judge
whether the present cognitive function of the subject is within anormal range. If the score of the test is below the SD at the corresponding age, the subject is regarded as abnormal. b Generally
speaking, cognitive function decreases with age. If we can identify
the formula for the change of test scores across the age, the for-mula for each subject (based on scores from several tests) can becompared with the average population’s formula. If the slope of theinclination is steeper than normal, it is possible that the cognitive
function of the subject will become abnormal in the future. SD,
standard deviation.

Online research service

Macromill Group Company
Area: Japan
Sex: allAge: 40–89 years
Onerous/free: onerous
Sample: 5,000
M : F = 2,500 : 2,500
Brain assessment
Incomplete: 892
Subjects for analyses: 4,108 (M : F = 2,055 : 2,053)
Raw scores of five versions

Age group, years:
40–49: 959
50–59: 834
60–69: 1,032
70–79: 825
80–89: 458

Calculation of the deviation values
Cognitive scores

2

Dement Geriatr Cogn Disord
DOI: 10.1159/000516564

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Fig. 2. Flow diagram of this study.

Subtest

Mean (sec) ±SD

Memory of numbers
Memory of words
MRT
N-back test
Judgment

295±32296±30260±61286±40279±53SD, standard deviation; MRT, mental rotation test.

control of hypertension is seen in only 28% of patients [1].
Similarly, for diabetes mellitus (DM), in only 1 of 4 DM
patients, it is well-controlled [2]. While patients may recognize the importance of controlling their diseases, theyoften ignore the control measures they should be taking
due to their hectic life schedules. We thus need to findopportunities that provide them with the strong motivation they need to immediately and enthusiastically address the problem and to begin to improve their lifestyles
accordingly.
There are various tests in order to assess the subjects’
cognitive function. For example, we developed Necker
cube drawing-based assessment battery useful for detecting mild constructional apraxia which is one of the early
symptoms of Alzheimer’s disease [3]. We also reported
that the missing fundamental phenomenon was impaired
in individuals with Alzheimer’s disease, and suggested its
impairment represents a manifestation of the degeneration of auditory-related brain regions [4]. But the current
tests, including ours mentioned previously, have several
limitations. First, these tests set mean scores and standard
values. If the subject’s score is below the standard value ofthe corresponding age-group, the cognitive function of
the subject is considered abnormal (Fig. 1a). On the contrary, cognitive function of a subject is not consideredabnormal if the score is within normal limits. We hypothesize that if people became aware that their cognitive
function is decreasing more rapidly than the norm
(Fig. 1b), they will be more likely to take underlying problems seriously. Therefore, it will be useful if we can know
not only the present cognitive function but also whether
the speed of cognitive decline due to aging is within thenormal limit or not. Second, most of the existing cognitive tests have only one version. This enables the subject
to become accustomed to the contents of the test throughrepeated testing, so several versions are necessary to prevent this habituation because this habituation may allow
the subject achieve a higher score surpassing the actual
Online Cognitive Test (Brain Assessment)

abilities that is not truly reflective of performance. And
third, due to the ongoing outbreak of the coronavirus disease 2019 (COVID-19), in-person assessment is difficult.
Thus, an online test is desired.
Here, we have developed an online test to detect abnormal cognitive decline. The cognitive domains assessed include memory, visuospatial abilities, working memory,and judgment. We collected the online test results from
5,000 subjects and calculated the mean score and standard
deviation (SD) for each age. From this we determined theformula for cognitive decline due to normal aging.

Materials and Methods
Subjects
The subjects were gathered voluntarily by the use of Internet
flyers for participation, provided by an Internet research service
Macromill Group Company. The total number of subjects was
5,000, consisting of an equal number of males and females, withages ranging from 40 to 89 years (Fig. 2). The same number of men
and women was recruited in the order of arrival of participation
requests. Subjects performed one version of our cognitive test
(brain assessment, BA) online, details of which are explained later.
The version of what was assigned to the subject was randomly assigned. The subjects were ordered to complete the test within 5
min. The mean performance time of each subtest is shown in Table 1. In the mental rotation test (MRT) and the judgment test, themajority of the subjects were able to complete the test; therefore,
their performance times were relatively short. We excluded thosesubjects whose performance time was short over 2 SDs since weassumed the subjects might have abandoned the tests halfway
through. Thus, the data from a total of 4,108 subjects were utilized
for statistical analyses. The number of subjects from each age range
is shown in Figure 2. We cannot completely exclude the possibility that patients with mild cognitive impairment were included in
the subjects. But because of the following reason, the subjects withdementia are thought to have been excluded even in its early stage.
In Japan, the old persons who can make free use of the Internet are
relatively small. According to the data of White Paper Information
and Communication in 2018 by the Ministry of Internal Affairs
and Communications, only half of the elderly from 70 to 79 years
can use the Internet. As for the persons older than 80 years, the rate
decreases to almost 20%. So, only by the fact that he/she could operate the novel device and apply the participation through the Internet, we may say that they preserved the ability of novelty-seeking, willingness, and dealing with the inexperienced situation.
Therefore, we can reasonably conclude that the cognitive functionof the old participants to this study was relatively preserved.
Brain Assessment
The cognitive tests consisted of 5 subtests: number and word
memory, mental rotation task, N-back task, and judgment (Table 2). All the tests could be performed online by clicking an answer on the screen. We named the combined package of these tests
the “BA.” The BA has 5 versions, and feedback regarding correct/
wrong answers to the questions was not provided to the subjects.

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Table 1. Performance time for each test

Table 2. Contents of the test (BA)

Cognitive domain Subtest

How-toMemoryNumbers

The subject must memorize numbers from 3 to 9 digits, and repeat them using the numeric
keypad in ascending and descending order

Words

Memorize 5 target words. After a short distracting task, 10 words in which half of them belong to
the target words are presented in order. The subject replies whether each word was included
among the target words

MRT

A 3-dimensional target block figure is presented. Four rotated alternatives, one of which isdifferent from the target, are then presented. The subject selects which alternative is different

Visuospatial

Working memory N-back test

A series of numbers is presented. The subject must perform addition of the present and several
antecedent numbers

General intellect

The subject must find the regularity in the presented figures

Judgment

BA, brain assessment; MRT, mental rotation test.

Memorize the numbers below.
2

3

1From
2 left3

Next

Memorize the numbers below.
45Fig. 3. Example of the number memory

subtest. Two kinds of tasks were carriedout: type the presented numbers from theleft (upper) or from the right side (lower).
The number of digits in each presented sequence ranged from 3 to 9.

The subtest for number memory was performed as follows(Fig. 3). Numbers ranging from 3 to 9 digits were presented, andthe subjects were asked to memorize these numbers. On the next
slide, the subjects performed 2 kinds of tasks. Using the numeric
keypad on the screen, the subjects entered the numbers from theleft or from the right side (ascending or descending, respectively).
The time spent on each slide was determined by the subjects, andthey were required to click the “next” button on the slide when theyfinished answering. The subjects performed as many tasks as possible over 5 min, and one point was given when both the number
and its numerical position were correct.
For the word memory subtest, 6 words were presented on thefirst slide (Fig. 4). Three to 5 distracting slides then followed; these4

Dement Geriatr Cogn Disord
DOI: 10.1159/000516564

2

3

4

5

6

7

8

9

0

Redo

Click the numbers beginning from theright as shown on the previous slide.
1From2right3

6

1

Next

1

2

3

4

5

6

7

8

9

0

Redo

consisted of 6 numbers, and the subjects were asked to click the
fourth biggest one, for example. Then, on the following slides, aword was shown, and the subjects were asked whether the word
was included among the words on the first slide by clicking a yesor a no button. Ten words were shown, among which half were
included on the first slide. The time spent on each slide was determined by the subjects, and they were required to click the “next”
button on the slide when they finished answering. The subjects
answered as many questions as possible over 5 min. One point wasgiven for each correct answer.
The third subtest was an MRT. The MRT was first described by
Shepard and Metzler in 1971 [5]. The stimuli consisted of 2-dimensional drawings of the 3-dimensional objects (Fig. 5). The tar-

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1

Click the numbers beginning from theleft as shown on the previous slide.

Memorize the six words below.

Select the fourth largest number.

apple

house

cherry

3

fish

book

dish

5

1

6

2

4

Next

Next

Was the following word included
within the six-word list previously
shown?

Select the third largest number.
12

2

36

Choose the figure that is different from theone on the left.

Fig. 5. Target 3-dimensional figure was presented on the left sideof the slide. Four alternatives, of which 3 were rotated versions of
the target, were presented on the right side of the slide. The subjects
were asked to pick which figure was different from the target byclicking on it.

get figure was presented on the left side of the slide, and 4 alternatives, among which 3 of them were rotated figures of the target,
were shown on the right. The subjects were asked to click the figurethat was different from the target. The subjects performed as manytasks as possible over 5 min. One point was given for each correct
answer.
The fourth subtest was the N-back test. The subjects were asked
to memorize the presented number. In the case of the 1-back test
(Fig. 6), the subjects added the number to that on the first slide andanswered by clicking one of several choices. At the same time, thesubjects had to memorize the number of the second slide and add
it to the number on the third slide. The same process was repeated.
In the 2-back test (Fig. 7), the subjects memorized 2 numbers

Online Cognitive Test (Brain Assessment)

24

15

45

Next

cherry1–3
similarquestions

Yes

No
Next

which were presented on the first and the second slide, then wereasked to add the first number to that on the third slide, and memorize the number on it. The subjects performed these tasks up to
the 3-back test. The timing spent on each slide was determined by
the subjects, and they were required to click the “next” button on
the slide when they were finished answering. The subjects performed as many tasks as possible over 5 min. One point was given
for each correct answer.
The final subtest was for judgment and speculation (Fig. 8).
Several figures and operations were shown. Using operations A
and B, some changes appeared to the original figures. The subject
had to decide which operation had changed the original figure, byclicking the correct answer from among 4 alternatives. One point
was given for each correct answer. Eighteen tasks were performed,
and the total score was out of 18.
The number and word memory tests might be based on thefunctional activity of the medial temporal lobes, which include thehippocampus. It was reported that during the mental rotation task,
activation was observed in the parietal, frontal, and occipital lobes,
which represent Brodmann’s areas 7, 8, and 19, respectively [6].
The N-back task has a relationship with the activity of frontoparietal regions [7, 8]. A meta-analysis of 27 experiments showed thatthe relational reasoning task activated the rostrolateral prefrontal
cortex [9]. So, it seems reasonable to suppose that the BA reflects
the function of frontal, temporal, parietal, and occipital lobes,
namely, the entire cerebrum. Now, the BA is used for research purposes, and it will be opened to public at a fee when this manuscript
is published.
Calculation of Cognitive Score
We controlled the difference of the 5 versions of the BA by using the following equation to standardize the raw scores as themean score became 50, where the SD became 10. Such standard-

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Fig. 4. Six words were presented, and thesubjects were asked to memorize them.
Then, 3 to 5 distracting slides were shown.
These consisted of 6 numbers, and the subjects were asked to click the fourth biggest
one, for example, on the next slides, a word
was presented, and subjects were asked
whether the word was included among the
6 words on the first slide.

Memorize the number below.

Add the number below to the numberthat was prevoiusly shown and choose
the answer from the alternatives(blue). Memorize the number below.

1

2

2

3

4

12

13

14

7

8

9

Next

Add the number below to the numberthat was initially shown and choose
the answer from the alternatives(blue). Memorize the number below.

5

2

3

4

12

13

14

7

8

9

5

10
15

6

11

16

Next

Memorize the number below.

3

8

Next

2 numbers shown on the first and the second slide. On the third slide, a number waspresented, and the subjects were asked to
add the number to the number on the firstslide and to click on the answer from thealternatives. On the fourth slide, anothernumber was shown, and the subjects wereasked to add it to the second one.

5

2

3

4

12

13

14

7

CS = ([raw score] − [mean of raw scores]) /[SD of raw scores] × 10 + 50
We then calculated the mean CS for each sex and age, plotted
the relationships between ages and mean CSs on figures, and calculated the formula of cognitive changes by normal aging. We per-

Dement Geriatr Cogn Disord
DOI: 10.1159/000516564

Next

Add the number below to the first of
the initially shown numbers andchoose the answer from thealternatives (blue).
Memorize the number below.

ized scores were termed the “cognitive score (CS).” The CS can becalculated using the following formula:

6

16

Next

Memorize the number below.

Fig. 7. 2-back test. The subjects memorized

15

6

11

8

9

5

10
15

6

11

16

Add the number below to the secondof the initially shown numbers andchoose the answer from thealternatives (blue).
Memorize the number below.

7

2

3

4

12

13

14

7

8

Next

9

5

10
15

6

11

16

Next

formed regression analysis and got the coefficient of determination (R2), using IBM SPSS Statistics 23 software.
We used online not personal computer (PC) software becauseof the following 3 reasons: the biggest most important reason wasits affordability. Because PC software needs to be downloaded,available PCs are limited. We assume that the BA can be used inhealth checks, for example, at companies and municipal corporations. These subjects will utilize the BA for many years. By using

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Fig. 6. 1-back test. The subjects were asked
to memorize the presented number, and on
the second slide, to add the number to thaton the first slide. The subject answered byclicking one of several choices, and at thesame time, they had to memorize the number of the second slide and add it to thenumber on the third slide. The same process was repeated.

5

10

The figures change as shown below
according to two operations (A, B).

A

B

What happens with operation B?
Choose from following alterations.
180° rotation

Add vertical line

90° rotation

Shrink

Fig. 8. Subtest of judgment. Some changes

were made to 2 original figures by operation A or B. The subjects were asked which
figure had changed the presented figure, byselecting the answer from 4 alternatives.

Results

In order to complete the BA, the subjects needed to beonline for approximately 25 min (see the Table 1). The
mean raw scores of 5 versions of the subtests are age-stratified by 5 years for each sex (Table 3). To resolve the differences in the levels of difficulties between the 5 versionsof subtests, we standardized the raw scores and calculated
the mean CSs for each age (see online suppl. material; see
www.karger.com/doi/10.1159/000516564 for all online
suppl. material) and by 5-year increments of age (Table 4)of each sex. Figure 9 shows the relationship between theage and mean CSs for each subtest. It is obvious that CSsof all subtests decreased with aging. This suggests thatcognitive function starts to gradually decrease in the 40s.
We calculated the formula of regression lines for each
subtest in each sex. The regression coefficient was from
−0.31 to −0.45. It is noteworthy that in most of the subtests, the CSs consistently decreased until 80 years of age,
but turned upward at 85 years of age.
Online Cognitive Test (Brain Assessment)

Discussion

The present study can be summarized by the following
7 main points: (i) we described the “BA” which consistsof multifaceted cognitive domains; (ii) the BA has 5 versions and can be completed on the Internet within 30
min; (iii) data for a large number of subjects whose age
ranged from 40 to 89 years were collected; (iv) to resolve
the differences in the levels of difficulties between the 5versions, we standardized the raw scores and calculated
mean CSs for each age-group stratified by 5 years; (v) the
CS of most subtests decreased linearly with age until age
80 years; (vi) we drew the lines of the best fit and calculated the formulas of cognitive decline by normal aging;
finally, (vii) at 85 years of age, the CS trended toward an
improvement.
Our “BA” has 3 key characteristics. First, the BA canbe done on a PC using the Internet, and its scoring is automated, without the need for specialists. Anyone caneasily access the test at any time, alleviating the risk ofinfection through in-person contact. Second, it can encompass a large number of subjects. In Japan, there are 3
standardized intellectual tests which assess general cognitive function: the Japanese version of the Wechsler Adult
Intelligence Scale-Third Edition (WAIS-III) [10], Raven’s Colored Progressive Matrices (RCPM) [11], and theMini-Mental State Examination-Japanese (MMSE-J)[12]. The total number of subjects used for the standardization of normal values was about 1,400, 300, and 330 for
the WAIS-III, RCPM, and MMSE-J, respectively. In contrast, the BA obtained data from over 4,000 subjects.
Third, standard values of CSs are provided for a wider
range of ages in the BA. The age range for the standard
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online software, it is easy to preserve data, and the subjects can access them anytime and anywhere; the second reason is economic
efficiency. There are multiple operating systems in the world, andin the case of PC software, we must revise the program as soon as
the version or its content is upgraded. In online software, the frequency of such revisions will be much less than PC software, so thecost will be smaller; the third reason is easy maintenance. In PC
software, the subjects must upgrade the BA when it is versionupped. In online software, the subjects can perform the BA only byaccessing the Internet. Based on the reasons mentioned previously, we suppose online software is more suitable to the BA, rather
than the PC one.

Table 3. Mean raw scores for each subtest by age (years) and sex
Version

1

2

3

4

5

age, years

malemean ± SD

femalemean ± SD

malefemalemean ± SD mean ± SD

malefemalemean ± SD mean ± SD

malefemalemean ± SD mean ± SD

malefemalemean ± SD mean ± SD

Memory of numbers
117.2±28.6
40∼112.2±26.3
45∼107.2±29.5
50∼96.6±20.055∼94.5±26.460∼85.5±18.0
65∼76.6±21.970∼65.9±20.375∼
61.3±20.180∼62.0±18.1
85∼

109.7±33.5
107.1±25.8
91.0±28.7
92.8±19.785.2±19.4
82.9±27.2
75.6±25.7
69.4±21.5
67.7±28.578.3±36.3

111.4±21.8 112.7±29.7
120.6±25.1 106.3±29.4
101.5±24.4 94.2±27.1
103.5±26.8 101.2±25.9
90.1±22.9 81.3±23.2
85.0±20.0 78.5±21.9
73.5±23.1 72.4±24.5
69.6±22.6 72.9±20.7
60.6±21.7 64.0±31.2
64.4±12.1 81.4±31.3

115.4±30.7 104.9±27.7
114.6±29.3 101.2±20.7
105.7±25.6 96.1±23.6
93.3±25.1 92.3±22.6
93.8±23.9 84.3±22.0
82.4±26.4 79.4±26.1
71.6±23.8 70.9±23.7
72.8±19.0 68.2±21.5
62.2±23.3 65.2±27.1
80.7±30.0 77.3±21.0

122.1±26.5 111.7±24.7
110.0±24.1 104.2±23.8
110.0±25.2 97.6±27.7
96.6±27.2 92.0±23.1
94.8±25.1 88.7±19.4
87.5±26.2 78.7±22.7
77.4±25.3 74.4±23.0
71.6±20.4 65.7±25.9
63.0±17.2 64.4±31.8
62.8±19.3 78.3±37.9

108.6±26.5 105.5±26.1
114.6±24.4 99.2±26.1
106.0±30.0 96.6±25.9
97.8±32.4 89.1±26.9
91.9±23.2 83.9±26.6
88.2±23.5 78.2±22.1
77.5±27.9 72.8±23.9
72.7±18.5 68.2±28.0
55.7±18.9 60.8±20.4
61.5±13.1 63.8±21.5

Memory of words
45.0±9.440∼41.3±10.245∼37.5±11.750∼39.7±8.155∼36.4±7.960∼34.4±7.865∼30.4±8.270∼26.3±5.575∼24.3±8.280∼26.6±7.485∼42.8±11.6
41.8±8.0
38.7±8.1
37.1±8.2
36.2±6.5
35.5±8.2
33.9±8.530.1±8.5
30.0±9.7
32.6±13.0

44.0±10.445.3±7.541.3±6.8
39.9±8.935.5±6.934.8±8.831.9±8.2
29.9±9.426.8±7.726.8±6.2

43.6±8.4
40.7±9.6
38.4±9.2
40.8±7.638.3±6.4
35.9±8.933.7±7.0
33.5±11.1
28.9±8.2
35.1±9.442.4±12.3
43.5±8.3
40.8±9.4
38.6±8.2
37.1±8.0
34.0±8.930.7±8.1
28.0±5.825.4±9.525.0±8.3

44.7±9.442.3±7.940.9±6.9
39.0±6.4
38.4±8.3
35.3±7.433.4±7.430.8±8.2
30.0±9.3
30.5±7.2

44.8±8.0
41.4±8.941.3±7.738.4±8.7
38.8±8.0
34.9±7.0
32.5±8.831.0±7.1
28.8±7.529.1±6.6

42.7±8.941.9±6.9
41.6±7.937.6±5.537.8±6.9
34.6±8.933.7±8.1
28.7±7.932.3±9.7
33.0±9.4

42.9±9.3
41.8±10.2
41.3±8.538.9±12.7
37.7±8.6
36.0±8.3
32.0±9.4
29.4±8.0
25.0±6.8
23.7±8.443.5±8.8
41.7±8.741.3±7.3
37.0±7.938.4±8.2
37.4±6.8
32.4±7.730.6±8.6
30.8±8.3
27.5±9.2

Visuospatial
40∼
45∼
50∼
55∼
60∼
65∼
70∼
75∼
80∼
85∼

12.1±3.5
11.7±2.6
10.8±2.6
10.6±2.3
9.3±2.1
9.2±2.2
8.2±1.97.7±1.6
7.2±1.5
8.3±2.49.9±1.9
10.0±2.1
8.5±1.88.5±1.98.3±1.97.7±1.87.9±2.1
7.3±2.1
7.6±2.3
7.5±1.4

11.4±2.5
11.7±2.2
11.0±2.8
10.0±2.7
9.5±1.98.8±2.3
8.0±1.97.3±2.1
7.2±2.0
7.6±1.89.5±2.4
9.5±1.99.1±2.2
9.3±2.0
8.2±1.97.9±1.97.4±1.8
6.8±2.1
7.5±2.7
9.6±2.3

11.6±2.8
11.7±2.5
11.7±2.2
10.8±2.1
10.0±2.3
9.2±2.5
9.0±1.78.2±1.6
7.8±2.1
7.4±2.2

10.1±2.0
9.3±2.3
9.9±2.0
9.2±2.0
8.9±2.2
8.8±2.0
7.3±1.77.5±2.1
7.5±2.4
8.8±2.812.3±2.4
13.0±2.4
12.9±2.2
11.3±2.510.8±2.2
10.2±1.8
9.1±2.2
8.1±2.1
8.7±1.98.9±2.2

11.0±2.2
9.9±2.4
10.0±2.4
9.8±2.2
9.4±2.2
8.5±2.3
8.2±1.97.4±1.6
9.3±3.0
8.4±2.0

11.8±2.5
11.9±2.6
11.1±2.3
10.7±3.1
10.0±2.1
9.1±1.68.8±1.99.0±1.97.8±1.98.3±1.7

10.4±2.2
10.1±2.2
9.9±1.89.1±1.89.0±2.0
8.4±1.98.0±1.97.8±1.8
8.6±2.6
9.1±2.7

Working memory
36.2±10.340∼32.4±10.445∼28.3±11.950∼28.9±10.1
55∼
28.6±8.560∼
27.9±10.765∼22.6±10.270∼21.1±10.575∼17.2±8.980∼
16.6±5.785∼34.4±11.1
33.0±10.528.5±9.525.2±10.4
27.2±10.3
25.5±8.722.3±11.4
18.0±9.6
18.4±11.4
25.3±13.6

34.1±9.935.0±9.729.3±11.8
30.8±11.5
27.3±9.0
26.5±8.823.5±10.1
22.5±10.3
16.6±8.717.1±10.534.4±10.433.2±8.729.4±11.0
30.0±9.0
26.6±8.524.5±10.2
21.1±9.818.3±10.3
16.6±13.3
21.4±14.434.5±11.7
32.2±11.4
32.4±10.431.4±10.2
28.6±9.3
24.7±10.2
21.8±8.920.1±7.0
15.0±9.1
23.1±13.1

30.5±10.528.9±9.2
28.5±9.429.1±8.826.7±10.6
23.1±11.2
21.1±8.4
18.2±10.8
16.8±10.2
21.7±11.0

33.7±11.0
33.3±11.0
29.4±11.0
30.3±10.1
26.9±9.825.4±8.8
23.7±11.2
19.1±7.419.1±7.5
16.0±6.3

33.3±8.932.2±9.830.4±9.427.2±9.3
27.3±10.0
24.1±10.2
21.3±7.9
15.7±7.3
16.7±11.9
26.1±11.5

31.0±13.0
34.5±10.2
30.2±11.3
28.9±12.6
27.6±8.825.9±9.3
24.0±9.0
19.6±7.2
13.9±7.8
9.8±6.832.1±7.829.9±10.030.8±9.0
25.0±9.926.8±9.0
24.7±7.8
19.8±9.718.8±10.5
16.5±10.1
13.5±5.8

General intellect
12.7±3.440∼11.8±3.945∼11.0±3.150∼11.1±2.855∼10.2±2.760∼
8.9±3.165∼
8.0±2.570∼
6.8±2.375∼
6.5±2.780∼
5.3±3.485∼

11.4±3.0
10.4±3.7
8.7±2.99.4±2.99.5±2.3
7.8±2.7
7.1±2.5
6.0±2.1
6.7±3.3
9.3±4.5

12.7±3.1
12.2±3.2
10.4±3.8
10.4±3.2
9.8±2.7
9.0±2.8
7.5±2.5
6.6±2.4
5.7±1.94.3±1.1

11.1±3.4
10.8±3.0
9.5±3.5
9.1±3.4
7.9±2.8
7.6±2.7
6.4±2.5
6.2±2.7
5.5±4.0
8.1±2.811.4±4.4
11.7±4.3
10.7±3.8
10.3±4.1
9.7±3.1
7.8±3.4
6.6±2.95.7±2.0
4.5±2.4
7.0±4.3

10.6±3.8
9.0±4.0
9.0±3.88.7±3.2
7.6±2.9
6.7±3.55.3±2.2
4.6±2.4
4.6±2.6
7.2±3.4

11.2±3.3
11.2±3.2
11.6±3.2
10.4±3.1
9.7±3.7
8.0±2.8
7.4±2.8
6.7±2.0
5.6±2.5
6.5±2.6

10.1±2.8
8.6±2.98.6±2.5
8.7±3.0
7.9±2.7
7.1±3.3
5.7±1.95.3±2.2
6.4±3.0
8.1±2.7

11.4±3.4
12.0±3.1
10.9±2.5
10.1±3.5
9.6±3.0
8.1±2.8
7.7±3.1
6.3±2.4
5.5±2.1
5.5±1.3

10.4±3.2
10.2±3.1
9.6±3.1
9.2±2.88.3±3.0
6.8±2.4
5.9±2.3
6.2±2.8
6.0±3.2
6.0±2.1

8

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SD, standard deviation.

Dement Geriatr Cogn Disord
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9

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55.6±6.3
53.8±5.952.1±5.850.9±5.749.4±5.347.2±5.744.8±5.242.9±5.843.1±7.8
46.6±7.858.1±7.2
57.9±6.5
55.4±6.7
53.7±6.7
51.7±5.649.2±5.746.3±5.844.1±4.741.3±4.942.2±5.655.9±9.0
53.4±9.4
51.4±8.951.2±8.549.1±7.846.3±8.2
43.1±6.5
42.0±6.942.5±8.947.9±9.459.0±9.958.9±9.856.4±9.055.3±9.2
53.4±8.449.4±8.2
46.9±7.644.1±6.4
41.6±6.6
41.9±8.456.1±8.4
54.7±8.4
53.1±8.3
51.2±8.3
50.9±8.3
48.7±8.3
45.9±8.2
43.2±8.542.5±9.6
46.4±10.756.7±9.856.5±9.1
53.4±9.853.6±9.3
51.6±7.950.2±8.2
47.6±8.645.4±7.441.8±7.3
42.0±8.1
SD, standard deviation; CSs, cognitive scores.

40∼
45∼
50∼
55∼
60∼
65∼
70∼
75∼
80∼
85∼

58.6±9.2
58.4±8.855.7±9.2
52.7±8.951.3±8.2
48.9±7.845.3±8.2
43.8±6.940.3±6.942.0±6.9

56.7±9.654.8±8.5
52.0±8.951.5±8.0
48.5±7.546.8±8.1
44.7±8.1
43.2±8.0
41.7±9.445.8±10.3

56.3±9.4
54.6±8.1
53.2±7.751.2±7.1
50.8±7.2
48.8±8.0
46.5±7.643.9±8.7
43.8±9.045.3±9.759.5±10.760.2±9.6
58.0±9.655.1±10.052.2±8.2
49.8±8.3
47.1±7.645.1±7.5
43.7±7.345.3±256.6±9.955.5±9.0
53.3±8.952.0±9.1
50.1±7.847.9±8.0
44.7±8.442.2±7.439.3±7.8
39.8±7.3
214/240295/267
225/249
213/207311/312240/255
291/360
105/103
243/14643/51

53.2±8.3
51.7±8.6
50.6±8.1
49.3±7.8
47.7±7.945.6±7.943.8±7.442.4±7.645.1±10.2
47.9±9.6

malefemalemean ± SD mean ± SD
malefemalemean ± SD mean ± SD
malemean ± SD
femalemean ± SD
malemean ± SD

femalemean ± SD

malefemalemean ± SD mean ± SD

Total
General intellect
Working memory
Visuospatial
Memory of words

Subject
Memory of numbers
numbers
femalemale/female Malemean ± SD mean ± SD
Age,
years

Table 4. Mean CSs by age in 5-year increments

Online Cognitive Test (Brain Assessment)

values of the WAIS-III is below 75 years, although there
are many patients with dementia who are older than 80
years. In contrast, the BA provides standard values up to
89 years of age.
The BA can reveal not only the levels but also the longitudinal changes in cognitive function. The WAIS-III,
RCPM, and MMSE-J can determine cognitive function at
the time of testing, and if their results are within normal
limits, the subjects will be considered normal. The resultsof the BA can be described as abnormal if the longitudinalchange is worse than the normal rate of change, even if
the score itself is within the normal range. By repeating
this test for several years, subjects can determine the degree of their cognitive decline. As described in Introduction, about 70% of hypertension and three-fourths of DM
patients do not adequately control their disease. For theprevention of dementia, the control of these lifestyle-related diseases is very important, especially beginning in
middle age. The results of the BA may motivate the subjects to improve their lifestyles and thus reduce the risk ofrelated diseases.
Notably, in most of the subtests, CSs consistently decreased until age 80 years (i.e., the group that consists ofsubjects aged 80–84 years), but started increasing at age
85 years (i.e., the group consisting of subjects aged 85–89
years). This increase may be caused by biological selection bias. The mean life span of Japanese individuals is
about 81 years for male and 87 years for female individuals. This means that someone who can complete the BA
on a PC at the age of 85 years or older may be in excellent
cognitive and physical condition compared with the standard elderly persons. Therefore, we speculate that this is
the reason for improved results of cognitive tests in the 85
age-group.
The present study has several limitations that should be
noted. First, information pertaining to the educational history was not accounted for. However, given the large number of subjects for the standardization, we believe this would
negate any differences. Second, correlations between the
BA and WAIS-III, RCPM, or MMSE-J were not performed.
We understand the importance of these analyses and will
undertake these comparisons in the near future. Third, thepossibility that patients with mild cognitive impairment
were included among elderly subjects could not be completely excluded. But the fact that they could deal with thenovel device suggested that their cognitive function was relatively preserved. Last, longitudinal changes in the BA
scores for the same subjects are yet to be assessed. Continuous follow-up of the subjects will enable us to ascertain individual rates of cognitive changes based on the results over

Male

Memory: numbers

6560

y = –0.472x + 78.876
R2 = 0.9856
40

50

60

70

80

90

Female

45
40

35
30

50

35

y = –0.4347x + 75.147
R2 = 0.9817
40

50

60

70

80

90

30

60

60

55

55

55

50

50

50

45

45

40

40

30

35

y = –0.3803x + 71.698
R2 = 0.9928
40

50

Male

60

Age

70

80

90

N-back test

60

40

50

50
CS

45
40

60

Age

70

80

90

Judgment

65

55

40

50

60

70

80

90

Female

30

55

55

50

50

45

40

50

60

70

80

90

30

55

50

50

50

45

45

45

CS

55

CS

55

30

40

40

50

60

Age

70

80

90

40

50

60

Age

70

80

90

Total CS (tCS)y = –0.4127x + 75.785
R2 = 0.9775
40

50

60

70

80

90

40

35
30

90

y = –0.3136x + 66.068
R2 = 0.9925

35

y = –0.4433x + 78.395
R2 = 0.9718

60

y = –0.3527x + 70.749
R2 = 0.9787

80

40

60

35

70

45

60

40

60

35

60

30

50

40

60

35

y = –0.3571x + 72.198
R2 = 0.9659

40

65

40

35
30

30

y = –0.3263x + 69.48
R2 = 0.9835

CS35

y = –0.452x + 79.42
R2 = 0.977

45
CS

CS

CS

45
40

35

CS

55
CS

CS

CS

45
40

CS

60

50

50

Mental rotation

65

55

55

30

Memory: words

60

y = –0.3643x + 70.182
R2 = 0.9628
40

50

60

Age

70

80

90

35
30

y = –0.3367x + 69.067
R2 = 0.9843
40

50

60

Age

70

80

90

Fig. 9. Mean CSs according to age. There is a clear negative correlation between the CSs and age for all subtests.

10

Dement Geriatr Cogn Disord
DOI: 10.1159/000516564

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It is noteworthy that in most subtests, the CSs consistently decreased until 80 years of age, but started to increaseat 85 years of age. CSs, cognitive scores.

several years, which will be nearly the same as the trends
detected in the present study. Despite these limitations, we
expect the BA to be useful for detecting longitudinal cognitive changes compared to the pattern seen in normal aging,
and we believe that it will be able to provide the motivation
for subjects to improve their lifestyles.
Conclusion

We developed a new cognitive function test, named theBA, which comprises various cognitive domains. The BA
can be easily performed on a PC online, and the standardization was carried out using the data from over 4,000 subjects ranging from 40 to 89 years old. We observed thatcognitive function linearly declines with normal aging. By
performing the BA every year, subjects will be able to detect any abnormal rates of the cognitive decline even if theresults themselves are within normal limits. This awareness may bring forth the motivation to improve aspects of
their lifestyles which are critical for dementia prevention.
Statement of Ethics

ration of 1975. All of the processes of the subject recruitment anddata collection were performed through the Internet, so all the participants provided informed consent by clicking the button of theInternet site of the Macromill Group Company.

Conflicts of Interest Statement
The Department of Dementia and Neuropsychology, Master
Program of Innovation for Design and Engineering, Advanced Institute of Industrial Technology, was established using donations
provided by the Research Institute of Brain Activation.

Funding Sourceses.

The study was conducted in the absence of any funding sourc-

Author Contributions
Masayuki Satoh: design of this study, interpretation of data,
and writing the manuscript. Ken-ichi Tabei: interpretation of data
and revision for important intellectual content. Saiko Fujita: analyses of data. Yoshinori Ota: design of this study and the acquisitionof data.

This study received approval from the Advanced Institute ofIndustrial Technology Research Ethics Committee [Approval No.:
19009] and was conducted in accordance with the Helsinki Decla-

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