The Digit Symbol Substitution Test for Dementia

Uses and Administration of the Digit Symbol Test in Dementia

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The Digit Symbol Substitution Test (DSST) is an evaluation tool used to assess cognitive functioning. It initially was part of the Wechsler Adult Intelligence Test (WAIS), a well-known test that measures an individual's intelligence quotient (IQ).

The DSST involves a key consisting of the numbers 1-9, each paired with a unique, easy-to-draw symbols and punctuation marks such as a "&", "+" or ">". Below the key are a series of the numbers 1-9 in random order and repeated several times. The test taker is then allowed 90 or 120 seconds (depending on the test version) to fill in the corresponding symbol for each number. This task requires the individual to visually scan the answer key provided at the top of the test and then write the correct symbol by each number.

Before beginning, the test taker should complete the practice questions provided to ensure that he or she understands the task. After the test is completed, the administrator will score the test, giving one point for each correct response.

Female doctor with digital tablet talking with senior male patient in examination room
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Other Names

  • Digit Symbol Coding Test
  • Symbol Digit Modalities Test
  • Digit Symbol Test

What Does the Test Measure?

The digit symbol test measures processing speed, working memory, visuospatial processing, and attention. In particular, this test appears to be sensitive to changes in people whose cognition is quite good, whereas other tests might be unable to differentiate between persons with normal cognition and those with just the beginnings of mild cognitive impairment.

Other Variations of the Test

Other versions include the switching of the symbols and the numbers. In this version, the symbol is provided and the person must write the correct number for each one.

Researchers and companies like BrainCheck are developing digital versions of the test to be used on an iPad or smartphone. This can be particularly beneficial for people who are slower with the manual pencil and paper method (e.g. patients with movement disorders like Parkinson's) and can simply tap on the screen.

Another option is the oral version of this test, where the correct answer (the number) is said verbally for each symbol provided. Administering the test orally allows someone who does not have the ability to write (or whose physical ability is hindered in some way, for example, by a stroke) to be able to take the test and provide the answers orally.

Scores on the Digit Symbol Substitution Test

Some research has found that how people score on this test can be predictive of their chances of developing dementia within five and 10 years.

In one study, more than 2,700 participants without dementia were administered the digit symbol test along with other cognitive tests. Some received a full diagnostic assessment for dementia after five years and others were assessed after 10 years. The researchers found that lower digit symbol test scores were correlated with a higher risk of developing dementia in both the five and 10-year groups.

A 2018 study found that the test is sensitive in detecting cognitive changes but less reliable about specifying a cause. It concluded that the test results are useful when combined with a psychiatric clinical evaluation, particularly when evaluating medication dosages.

Other Uses of the Digit Symbol Substitution Test

This test has been used for multiple purposes, including the following:

Assessing cognitive ability to drive a vehicle: Poor performance on this test has been correlated with poor driving ability in persons with dementia.

Concussion evaluation: Following a suspected concussion, this test is sometimes used to assist in evaluating cognitive functioning.

Multiple sclerosis: The DSST has been used to evaluate diagnosis, progression, and ability to continue to work a job in people with multiple sclerosis.

Parkinson's: This test can identify some early cognitive impairment in Parkinson's disease that might be missed by the mini-mental state exam.

Huntington's disease: The DSST is part of the Unified Huntington’s Disease Rating Scale which is used to assess functioning in Huntington's disease.

Mild cognitive impairment: Research has shown that the DSST is able to identify mild cognitive impairment (MCI), a condition that sometimes—but not always—progresses to a dementia such as Alzheimer's disease.

Major depressive disorder: The DSST has been effective in identifying cognitive changes in those experiencing major depressive disorder.

A Word From Verywell

The DSST is one of many tests that may be used to assess cognitive functioning. It's important to note that testing for dementia requires a full diagnostic workup, not just one screening test. If you're concerned about your mental ability or your performance on the DSST, be certain to call your healthcare provider for further evaluation.

12 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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Additional Reading

By Esther Heerema, MSW
Esther Heerema, MSW, shares practical tips gained from working with hundreds of people whose lives are touched by Alzheimer's disease and other kinds of dementia.