Montreal Cognitive Assessment (MoCA)

Purpose of the measure

The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for the detection of mild cognitive impairment. It was developed in response to the poor sensitivity of the Mini-Mental State Examination (MMSE) in distinguishing clients with mild cognitive impairment from normal elderly clients (Nasreddine et al., 2005). Thus, the MoCA is intended for clients with memory complaints who score within the normal range on the MMSE.

The MoCA assesses the following cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. The measure can be used, but is not limited to patients with stroke.

Available versions

The Montreal Cognitive Assessment was developed by Dr Nasreddine in 1996, then validated with the help of Chertkow, Phillips, Whitehead, Bergman, Collin, Cummings, and Hébert in 2004-2005.

Features of the measure

Items:
The items of the MoCA examine attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. These items are described in detail below.

1. Alternating Trail Making:
The examiner instructs the client to “Please draw a line, going from a number to a letter in ascending order. Begin here” (points to 1) and draw a line from 1 then to A then to 2 and so on. End here (points to E).

2. Visuoconstructional Skills – Cube:
The examiner gives the following instructions, pointing to the cube: “Copy this drawing as accurately as you can, in the space below“.

3. Visuoconstructional Skills – Clock:
Indicate the right third of the test sheet where a space is provided for the clock drawing item, and give the following instructions: “Draw a clock. Put in all the numbers and set the time to 10 after 11“.

4. Naming:
Beginning on the left, point to each figure and say: “Tell me the name of this animal”.

5. Memory:
The examiner reads a list of 5 words at a rate of one per second, giving the following instructions: “This is a memory test. I am going to read a list of words that you will have to remember now and later on. Listen carefully. When I am through, tell me as many words as you can remember. It doesn’t matter in what order you say them“. Checkmark the space allocated for each word the client produces on the first trial on the test sheet. When the client indicates that he/she has finished (has recalled all the words), or can recall no more words, read the list a second time with the following instructions: “I am going to read the same list for a second time. Try to remember and tell me as many words as you can, including words you said the first time“. Put a checkmark in the allocated space for each word on the test sheet the client recalls after the second trial. At the end of the second trial, inform the client that she/he will be asked to recall these words again by saying, “I will ask you to recall those words again at the end of the test“.

6. Attention:
Forward Digit Span: Give the following instruction: “I am going to say some numbers and when I am through, repeat them to me exactly as I said them“. Read the five number sequences at a rate of one digit per second.

Backward Digit Span: Give the following instruction: “Now I am going to say some more numbers, but when I am through you must repeat them to me in the backwards order“. Read the three number sequences at a rate of one digit per second.

Vigilance: The examiner reads the list of letters at a rate of one per second, after giving the following instruction: “I am going to read a sequence of letters. Every time I say the letter A, tap you hand once. If I say a different letter, do not tap your hand“.

Serial 7s: The examiner gives the following instruction: “Now I will ask you to count by subtracting seven from 100, and then, keep subtracting seven from your answer until I tell you to stop“. Give this instruction twice if necessary.

7. Sentence Repetition:
The examiner gives the following instructions: “I am going to read you a sentence. Repeat it after me, exactly as I say it [pause]. I only know that John is the one to help today.” Following the response say: “Now I am going to read you another sentence. Repeat it after me, exactly as I say it [pause]. The cat always hid under the couch when dogs were in the room“.

8. Verbal Fluency:
The examiner gives the following instruction: “Tell me as many words as you can think of that begin with a certain letter of the alphabet that I will tell you in a moment. You can say any kind of word you want, except for proper nouns (like Bob or Boston), numbers, or words that begin with the same sound but have a different suffix, for example, love, lover, loving. I will tell you to stop after one minute. Are you ready? [pause]. Now, tell me as many words as you can beginning with the letter F” [time 60 seconds]. “Stop“.

9. Abstraction
The examiner asks the client to explain what each pair of words has in common, starting with the example: “Tell me how an orange and a banana are alike“. If the subject answers in a concrete manner, then say only one additional time: “Tell me another way in which those items are alike“. If the client still doesn’t give the appropriate response (fruit), say “Yes, and they are also both fruit“. Do not give any additional instructions or clarification. After the practice trial say: “Now tell me how a train and a bicycle are alike“. Following the response, administer the second trial, saying: “Now, tell me how a ruler and a watch are alike“. Do not give any additional instructions or prompts.

10. Delayed Recall:
The examiner gives the following instruction: “I read some words to you earlier, which I asked you to remember. Tell me as many of those words as you can remember.” Make a checkmark on the test sheet for each of the words correctly recalled spontaneously without any cues, in the allocated space.

Optional: The client can be prompted with semantic category cues for any word that is not recalled. This is to elicit clinical information in order to provide the examiner with additional information regarding the type of memory disorder. For memory deficits due to retrieval failures, performance can be improved with a cue. For memory deficits due to encoding failures, performance does not improve with a cue. No points are awarded for words recalled from a cue.

Make a checkmark in the allocated space if they remembered the word with the help of a category cue. If not, give them a multiple choice cue.

Use the following category and/or multiple-choice cues for each word, when appropriate:

FACE: category cue: part of the body multiple choice: nose, face, hand

VELVET: category cue: type of fabric multiple choice: denim, cotton, velvet

CHURCH: category cue: type of building multiple choice: church, school, hospital

DAISY: category cue: type of flower multiple choice: rose, daisy, tulip

RED: category cue: a color multiple choice: red, blue, green

11. Orientation
The examiner gives the following instructions: “Tell me the date today“. If the client does not give a complete answer, then prompt accordingly by saying: “Tell me the [year, month, exact date, and day of the week]“. Then say: “Now, tell me the name of this place, and which city it is in.”

Scoring:
Sum all subscores. Add one point for a client who has had 12 years or fewer of formal education, for a possible maximum of 30 points. A final total score of 26 and above is considered normal. A final total score below 26 is indicative of mild cognitive impairment.

Below is a breakdown of how each item of the MoCA is to be scored:

Item How to score
Alternate Trail Making
(1 point)
Give 1 point if the following pattern is drawn without drawing any lines that cross:
1-A-2-B-3-C-4-D-5-E. Any error that is not immediately self-corrected earns a score of 0.
Visuoconstructional skills Cube (1 point) Give 1 point for a correctly executed drawing. Drawing must be 3D; all lines drawn; no lines added; lines are relatively parallel and lengths are similar (rectangular prisms are accepted). A point is not assigned if any of the above-criteria are not met.
Vosuoconstructional skills Clock (3 points) Contour (1 point): The clock face must be a circle with only minor distortion acceptable (e.g. slight imperfection in closing the circle).
Numbers (1 point): All clock numbers must be present with no additional numbers; numbers must be in correct order and placed in approximate quadrants on the clock face; roman numerals are accepted; numbers can be places outside the circle contour.
Hands (1 point): There must be 2 hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centered within the clock face with their junction close to the clock centre.
A point is not assigned for a given element if any of the above-criteria are not met.
Naming (3 points) One point each is given for the following responses: (1) camel/dromedary, (2) lion, (3) rhinoceros/rhino.
Memory (0 points) No points are given for Trials 1 and 2.
Attention (6 points) Digit span (2 points): Give 1 point for each sequence correctly repeated (the correct response for the backwards trial is 2-4-7).
Vigilance (1 point): Give 1 point if there are 0-1 errors (an error includes a tap on a wrong letter, or a failure to tap on letter A).
Serial 7s (3 points): This item is scored out of 3 points. Give 0 points for no correct subtractions; 1 point for 1 correct subtraction; 2 points for 2-3 correct subtractions; and 3 points if the client successfully makes 4-5 correct subtractions. Count each correct subtraction of 7 beginning at 100. Each subtraction is evaluated independently; that is, if the client responds with an incorrect number but continues to correctly subtract 7 from it, give a point for each correct subtraction. For example, a client may respond “92-85-78-71-64” where the “92” is incorrect, but all subsequent numbers are subtracted correctly. This is 1 error and the item would be given a score of 3.
Sentence Repetition
(2 points)
Give 1 point for each sentence correctly repeated. Repetition must be exact. Be alert for errors that are omissions (e.g., omitting “only”, “always”) and substitutions/additions.
Verbal fluency (1 point) Give 1 point if the 11 words or more are generated in 60 seconds. Record responses in the margins.
Abstraction (2 points) Only the last 2 item pairs are scored. Give 1 point to each item pair correctly answered.
The following responses are acceptable:
Train-bicycle = means of transportation, means of traveling, you take trips in both
Ruler-watch = measuring instruments, used to measure
The following responses are not acceptable: Train-bicycle = they have wheels; Ruler-watch = they have numbers.
Delayed recall (5 points) Give 1 point for each word recalled freely without any cues.
Orientation (6 points) Give 1 point for each item correctly answered. The client must tell the exact date and place (name of hospital, clinic, office). No points are awarded if client makes an error of 1 day for the day and date.

Time:
The MoCA takes approximately 10-15 minutes to administer for clients with mild cognitive impairment.

Subscales:
Visuospatial/Executive; Naming; Memory; Attention; Language; Abstraction; Delayed recall; Orientation

Equipment:
Only the MoCA test sheet and a pencil are required to complete the measure.

Training:
The MoCA should be administered by a health professional. No formal training is required to administer the measure.

Alternative form of the MoCA

MoCA – version 2 & 3 (English)
Two alternative versions of the MoCA (English) have been validated for use in instances when repeated administration is necessary, to avoid possible learning effects.

MoCA – modified for individuals with visual impairments
An alternative version of the MoCA has been validated for use with patients with visual impairments.

Please visit http://www.mocatest.org for further information and to download the alternative forms.

Client suitability

Can be used with: Patients with stroke.

Should not be used with:

  • Because the MoCA is heavily language dependent, it is likely to misclassify patients with aphasia.
  • The MoCA is not suitable for use with a proxy respondent as it is administered via direct observation of task completion.
In what languages is the measure available?

The MoCA has been translated into Arabic, Afrikaans, Chinese (Beijing, Cantonese, Changsha, Hong Kong, Taiwan), Czech, Croatian, Danish, Dutch, Estonian, French, Finnish, German, Greek, Hebrew, Italian, Japanese, Korean, Persian, Polish, Portuguese (Brazil), Russian, Serbian, Sinhalese, Spanish, Swedish, Thai, Turkish, Ukrainian and Vietnamese. These translations can be found at the following website: http://www.mocatest.org.