Montreal Cognitive Assessment

The Montreal Cognitive Assessment (MoCA) was created in 1996 by Dr. Ziad Nasreddine in Montreal, Canada. It was validated in the setting of mild cognitive impairment, and has subsequently been adopted in numerous other settings clinically.

The MoCA test is a one-page 30-point test administered in approximately 10 minutes. The test and administration instructions are freely accessible for clinicians at www.mocatest.org. The test is available in 35 languages or dialects. There are 3 alternate forms in English, designed for use in longitudinal settings.

The MoCA assesses several cognitive domains. The short-term memory recall task (5 points) involves two learning trials of five nouns and delayed recall after approximately 5 minutes. Visuospatial abilities are assessed using a clock-drawing task (3 points) and a three-dimensional cube copy (1 point). Multiple aspects of executive functions are assessed using an alternation task adapted from the trail-making B task (1 point), a phonemic fluency task (1 point), and a two-item verbal abstraction task (2 points). Attention, concentration and working memory are evaluated using a sustained attention task (target detection using tapping; 1 point), a serial subtraction task (3 points), and digits forward and backward (1 point each). Language is assessed using a three-item confrontation naming task with low-familiarity animals (lion, camel, rhinoceros; 3 points), repetition of two syntactically complex sentences (2 points), and the aforementioned fluency task. Finally, orientation to time and place is evaluated (6 points).

Validation study

The MoCA test validation study (Nasreddine et al., 2005) has shown the MoCA to be a promising tool for detecting Mild Cognitive Impairment (MCI) and Early Alzheimer's disease compared with the well-known Mini-Mental State Examination (MMSE). However, it had been established that the MMSE is not well suited for mild cognitive impairment, which raises the question whether it is an adequate "standard" to compare performance with the MoCA.

According to the validation study (Nasreddine et al., 2005), the sensitivity and specificity of the MoCA for detecting MCI (n=94 subjects) were 90% and 87% respectively, compared with 18% and 100% respectively for the MMSE. Subsequent work in other settings are less promising, though generally superior to the MMSE.

In the same study, the sensitivity and specificity of the MoCA for detecting Early AD (n=93 subjects) were 100% and 87% respectively, compared with 78% and 100% respectively for the MMSE. Normal Controls (n=90 subjects) had an average age of 72.84 and average education of 13.33 years.

Other applications

Since the MoCA assesses multiple cognitive domains, it may be a useful cognitive screening tool for several neurological diseases that affect younger populations, such as Parkinson's disease (5 studies showing the superiority of the MoCA over the MMSE), vascular cognitive impairment, Huntington's disease, brain metastasis, primary brain tumors (including high and low grade gliomas), and multiple sclerosis, and other conditions, such as traumatic brain injury, depression, schizophrenia and heart failure (See Reference section below).

Multiple cultural and linguistic variables may affect the norms of the MoCA across different countries and languages. Several cut-off scores have been suggested across different languages to compensate for education level of the population, and several modifications were also necessary to accommodate certain linguistic and cultural differences across different languages/countries. However, most of these versions have not been validated.

International Versions

Because MoCA is English specific, linguistic and cultural translations are made in order to adapt the test in other countries. For instance, in the Filipino version that is still being developed, Filipino translation of the English words is supplemented with changes in some of the images that locals can identify such as with the replacement of rhinoceros with an owl.^[1] The MoCA test is now us translated to 36 languages and dialects.^[2]

Recommendation

The MoCA has been recommended by:

The National Institutes of Health and the Canadian Stroke Consortium for detection of vascular cognitive Impairment (Hachinski et al. National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards. Stroke. 2006, Sep;37(9):2220-41).

The Canadian Consensus Guidelines for Diagnosis and Treatment of Dementia for detection of Mild Cognitive Impairment and Alzheimer’s disease (Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia, Alzheimer's & Dementia: The Journal of the Alzheimer's Association October 2007 (Vol. 3, Issue 4).

References

Alzheimer / MCI:

1. Fujiwara Y. et al. Brief screening tool for mild cognitive impairment in older Japanese: Validation of the Japanese version of the Montreal Cognitive Assessment. Geriatr Gerontol. Int. 2010;10:225-232.
2. Guo Qi-Hao et al. Application study of quick cognitive screening test in identifying mild cognitive impairment. Neuroscience Bulletin, February 2010, 26(1):47:54.
3. Walter Wittich, Natalie Phillips, Ziad Nasreddine, Howard Chertkow. Sensitivity and specificity of the Montreal Cognitive Assessment modified for individuals who are visually impaired. Journal of Visual Impairment & Blindness, June 2010, 104(6), 360-368.
4. Luis CA et al. Cross validation of the Montreal Cognitive Assessment in community dwelling older adults residing in the Southeastern US. International Journal of Geriatric Psychiatry, Online issue, October 21, 2008, published 2009;24: 197-201.
5. Koski L. et al. Measuring Cognition in a Geriatric Outpatient Clinic: Rasch Analysis of the Montreal Cognitive Assessment. Journal of Geriatric Psychiatry and Neurology, Volume 22, Number 3, Sept. 2009, page 151-160.
6. Rahman, Tomader Taha Abdel; El Gaafary, Maha Mohamed. Montreal Cognitive Assessment Arabic version: Reliability and validity prevalence of mild cognitive impairment among elderly attending geriatric clubs in Cairo. Geriatrics and Gerontology International, Volume 9, Number 1, March 2009, pp. 54–61 (8).
7. Jun-Young Lee et al. Brief Screening for Mild Cognitive Impairment in Elderly Outpatient Clinic: Validation of the Korean Version of the Montreal Cognitive Assessment. J Geriatr Psychiatry Neurol, June 2008, 21;2:104-110.
8. Tobinick et al. Rapid cognitive improvement in Alzheimer’s disease following perispinal etanercept administration. Journal of Neuroinflammation, January 2008, 5:2 (e-publication).
9. Wen HB et al. The application of Montreal cognitive assessment in urban Chinese residents of Beijing. Zhonghua Nei Ke Za Zhi. 2008 Jan;47(1):36-9. Chinese.
10. Smith T et al. The Montreal Cognitive Assessment: validity and utility in a memory clinic setting. Can J Psychiatry, 2007 May; 52(5):329-32.
11. J. Reban. Montrealsky kognitivni test/MoCA/: prinos k diagnostice predemenci, Ceska Geriatricka, Revue 2006 (4):224-229.
12. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment (MoCA): A Brief Screening Tool For Mild Cognitive Impairment. Journal of the American Geriatrics Society 53:695-699, 2005.

Parkinson

1. J.C. Dalrymple-Alford et al. The MoCA: Well-suited screen for cognitive impairment in Parkinson disease. Neurology 2010;75;1717
2. Meike Kasten et al. Validity of the MoCA and MMSE in the detection of MCI and Dementia in Parkinson's disease. Neurology 2010;75;478-479
3. Luo Xiao-Guang et al. Cognitive Deterioration Rates in Patients with Parkinson's Disease from Northeastern China. Dement Geriatr Cogn Disord 2010;30:64-70.
4. Hanna-Pladdy B. et al. Utility of the NeuroTrax computerized Battery for Cognitive Screening in Parkinson's Disease: Comparison with the MMSE and the MoCA. International Journal of Neuroscience, August 2010;120(8):538-43
5. Sarah H. et al. Pilot study of a three-step diagnostic pathway for young and old patients with Parkinson's disease dementia: screen, test and then diagnose. International Journal of Geriatric Psychiatry 2010; 25: 258-265.
6. Hoops S et al. Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease. Neurology 2009 Nov. 24 ; 73(21):1738-1745
7. Melzer T R et al. Cognition and the limbic system in early Parkinson's disease: A DTI investigation. Abstract NeuroImage 2009, 47 (Suppl. 1): S115.
8. Sarra et al. Montreal Cognitive Assessment Performance in Patients with Parkinson's Disease with "Normal" Global Cognition According to Mini-Mental State Examination Score. J Am Geriatr Soc Vol 57, Num 2, February 2009, pp. 304–308(5).
9. Lessig S. et al. Examination of the Montreal Cognitive Assessment (MoCA) and MMSE in Parkinson's disease (PD). Abstract T-82. Presented at American Neurological Association Meeting, Salt Lake City, Utah, September 24, 2008.
10. Gill DJ et al. The Montreal Cognitive Assessment as a screening tool for cognitive impairment in Parkinson's disease. Mov Disorders, Volume 23, No. 7, 2008. pp. 1043–1046
11. Zadikoff C et al. A comparison of the mini mental state exam to the Montreal cognitive assessment in identifying cognitive deficits in Parkinson's disease. Mov Disord. 2008 Jan 30;23(2):297-9.

Huntington:

1. Videnovic A. et al. The Montreal Cognitive Assessment as a screening tool for cognitive dysfunction in Huntington’s disease. Movement Disorders, 2010: 25(3):401-4.
2. Miches Laura et al. A Comparison of Two Brief Screening Measures of Cognitive Impairment in Huntington’s disease. Movement Disorders 2010, August 18. E-pub ahead of print.

REM:

1. Gagnon JF. Et al. The Montreal Cognitive Assessment: A Screening Tool for Mild Cognitive Impairment in REM Sleep Behavior Disorder. Movement Disorders 2010, May 15;25(7):936-40.

Vascular:

1. Cameron J. et al. Does cognitive impairment predict poor self-care in patients with heart failure? European Journal of Heart failure (2010) 12, 508-515.
2. Sarah T. Pendlebury et al. Underestimation of Cognitive Impairment by Mini-Mental State Examination Versus the Montreal Cognitive Assessment in Patients with Transient Ischemic Attack ans Stroke. A Population-Based Study. Stroke Journal of the American Heart Association, 41(6):1290-1293, June 2010.
3. Adrian Wong et al. The Validity, Reliability and Clinical Utility of the Hong Kong Montreal Cognitive Assessment (HK-MoCA) in Patients with Cerebral Small Vessel Disease, Dement Geriatr Cognitive Disorders, August 2009;28:81-87.
4. Martinic Popovic I. et al. Mild cognitive impairment in symptomatic and asymptomatic cerebrovascular disease. Journal of the Neurological Sciences, Volume 257, Issues 1-2, 15 June 2007, Pages 185-193.
5. Martinic-Popovic I. et al. Early detection of mild cognitive impairment in patients with cerebrovascular disease. Acta Clin Croat 2006;45:77-85.

Tumors:

1. Olson RA et al. Feasibility study of the Montreal Cognitive Assessment (MoCA) in patients with brain metastases. 0941-4355 (Print) 1433-7339 (Online) Supportive Care in Cancer. Wednesday, March 12, 2008, 16:1273-1278.
2. Olson RA et al. Prospective comparison of the prognostic utility of the Mini Mental State Examination and the Montreal Cognitive Assessment in patients with brain metastases. 0941-4355 (Print) 1433-7339 (Online) Supportive Care in Cancer. Tuesday, October 19, 2010, published online ahead of print. doi:10.1007/s00520-010-1028-1
3. Olson RA et al. Prospective comparison of two cognitive screening tests: Diagnostic accuracy and correlation with community integration and quality of life. Journal of Neuro-Oncology, accepted April 17, 2011, and published online ahead of print. doi:10.1007/s11060-011-0595-4

Schizophrenia:

1. Preda A, Adami A, Kemp AS, & Nguyen, D (2011). MoCA: A screening instrument for the assessment of cognition in schizophrenia. In Abstracts from the 13th International Congress on Schizophrenia Research, Schizophrenia Bulletin, 37(S1):225-226.

Reviews:

1. Zahinoor Ismail et al. Brief cognitive screening instruments: an update. Int J Geriatr Psychiatry 2010;25: 111-120.
2. Bredje A. Appels, MSc and Erick Scherder, Phd. The Diagnostic Accuracy of Dementia-Screening Instruments With an Administration Time of 10 to 45 Minutes for Use in Secondary Care: A Systematic Review. American Journal of Alzheimer’s Disease & Other Dementias 2010, 25(4) 301-316.
3. Lonie Jane A. et al. Screening for mild cognitive impairment: a systematic review. International Journal of Geriatric Psychiatry 2009; 24: 902-915.
4. Shiroky et al. Can you have dementia with an MMSE score of 30. Am J of Alzheimer’s Dis & Other Demen, Oct.-Nov. 2007;22:5;406-415.
5. Howe E. Initial screening of patients for Alzheimer’s disease and minimal cognitive impairment. Psychiatry, Volume 4 (7), July 2007, 24-27.
6. Gauthier et al. Mild cognitive impairment. Lancet. 2006 Apr 15;367(9518):1262-70, Review.
7. Hachinski et al. National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards. Stroke. 2006, Sept.;37(9):2220-41.
8. Allan L et al. Mild Cognitive Impairment: An Opportunity to Identify Patients at High Risk for Progression to Alzheimer’s disease. Clin Ther 2006;28:991-1001.

MoCA for the Blind:

1. Walter Wittich, Natalie Phillips, Ziad Nasreddine, Howard Chertkow. Sensitivity and specificity of the Montreal Cognitive Assessment modified for individuals who are visually impaired. Journal of Visual Impairment & Blindness, 104(6), 360-368, June 2010.