Montreal Cognitive Assessment (MoCA)

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the MoCA. As the MoCA is a relatively new measure, to our knowledge, the creators have personally gathered the majority of psychometric data that are currently published on the scale.

Reliability

Internal consistency:
Nasreddine et al. (2005) examined the internal consistency of the MoCA and reported an excellent Cronbach’s alpha (alpha = 0.83) on the standardized items.

Test-retest:
Nasreddine et al. (2005) examined the test-retest reliability of the MoCA by administering the measure to a subsample of 26 clients (clients with mild cognitive impairment or Alzheimer’s disease, and healthy elderly controls) twice, on average 35 days apart. The correlation between the two evaluations was excellent (r = 0.92). The mean change in MoCA scores from the first to second evaluation was 0.9 points.

Validity

Criterion:
Concurrent:
Nasreddine et al. (2005) administered the MoCA and the Mini Mental State Examination to 94 patients with mild cognitive impairment, 93 patients with mild Alzheimer’s disease, and 90 healthy elderly controls. The correlation between the MoCA and the MMSE was excellent (r = 0.87).

Responsiveness

Koski, Xie and Finch (2009) evaluated the MoCA as a quantitative measure of cognitive ability and its responsiveness. By applying Rasch analysis techniques to existing data from a geriatric outpatient clinic, the researchers found that in addition to the usefulness of the MoCA as a screening instrument, scores on the MoCA can be used to quantify the amount of cognitive ability a person has and can be used to track changes in cognitive ability over time. The significance of scores and change in scores can be interpreted based on the respondent’s baseline score, for example, a 5-point decrease from a baseline score of 25 is a more statistically significant and meaningful change than that of a 5-point decrease from a baseline score of 15 (please refer to Table 4 in Koski et al., 2009 for statistical significance of change in MoCA scores). Further research to determine the minimal clinically important difference is required.

Sensitivity and Specificity

Four studies examined whether the MoCA could detect patients known to have varying degrees of cognitive impairment and found the MoCA to be more sensitive than the Mini-Mental State Examination (MMSE) in detecting these differences.

Nasreddine et al. (2005) examined whether the MoCA could distinguish between patients with mild cognitive impairment and healthy controls. The DSM-IV and NINCDS-ADRDA criteria were used to establish diagnosis of Alzheimer’s disease and neurological assessments performed by neurologists and geriatricians were used to establish diagnosis of cognitive impairment. At a cutoff score of 26, the MoCA had a sensitivity in identifying clients with mild cognitive impairment and clients with Alzheimer’s disease of 90% and 100%, respectively, and a specificity of 87%. The MoCA’s sensitivity in detecting mild cognitive impairment was considerably more sensitive than was the Mini-Mental State Examination (MMSE) (the sensitivity of the MMSE was poor: 18% for patients with mild cognitive impairment; 78% for patients with Alzheimer’s disease).

Smith, Gildeh and Holmes (2007) evaluated whether the MoCA could detect mild cognitive impairment and dementia in patients attending a memory clinic. Dementia and mild cognitive impairment were diagnosed by neuropsychological assessment involving the ICD-10 criteria and CAMCOG scores. At a cutoff score of 26, the MoCA was found to have excellent sensitivity for detecting mild cognitive impairment (83%) and dementia (94%), but poor specificity (50% for both mild cognitive impairment and dementia). The specificity was lower than that identified in the earlier study by Nasreddine et al. (2005), likely due to the heterogeneous nature of the control group. The MoCA was also found to be more sensitive than the MMSE (the sensitivity of the MMSE was poor: 17% for patients with mild cognitive impairment and 25% for patients with dementia).

Luis, Keegan and Mullan (2009) examined whether the MoCA could distinguish between healthy controls and patients with Alzheimer’s disease or mild cognitive impairment. A diagnosis of Alzheimer’s disease was made by neuropsychological assessment using NINCDS-ADRDA criteria and mild cognitive impairment (MCI) by Petersen’s criteria (Petersen et al., 1999 as cited in Luis, Keegan & Mullan, 2009). At a cutoff score of 26, the MoCA was found to have excellent sensitivity for detecting MCI (100%) and Alzheimer’s disease and MCI combined (97%), with a poor specificity (35% for both groups of MCI and Alzheimer’s disease+MCI). A cutoff score of 23 was found to be optimal for identifying MCI, providing excellent sensitivity and specificity, 96% and 95% respectively. The MoCA was found to be more sensitive than the MMSE (at a cut-off score of ≤ 24, MMSE sensitivity for detecting MCI and Alzheimer’s disease+MCI was 17% and 36% respectively).

Dong et al. (2010) evaluated the sensitivity and specificity of an alternative language version of the MoCA for detecting vascular cognitive impairment and dementia after stroke. Patients underwent neuro-imaging and neuropsychological assessment in order to establish a diagnosis of cognitive impairment or dementia using the DSM-IV criteria. Using an optimum cutoff score of 21, the MoCA correctly identified 90% of patients with cognitive impairment (excellent sensitivity) and 77% of those without cognitive impairment (adequate specificity). The MoCA was also found to be more sensitive than the MMSE (MMSE sensitivity of 86% and specificity of 82% for detecting cognitive impairment).

In a population-based study of 413 patients with stroke or TIA, the MoCA was found to detect more cognitive deficits than the MMSE. For the purposes of the study, a score of ≥ 27 on the MMSE was used to classify patients as having normal cognitive function, and < 26 on the MoCA to classify mild cognitive impairment (no formal neuropsychological testing was performed to confirm diagnosis). 58% of patients with normal MMSE scores (≥ 27) were found to have scores indicative of mild cognitive impairment when the MoCA was used for screening (<26). Several of the deficits detected by the MoCA were in domains either not assessed or detected by the MMSE, including executive function and attention (not assessed) and recall and repetition (not detected) (Pendlebury, Cuthbertson, Welch, Mehta & Rothwell, 2010). Sensitivity and specificity of the MoCA for cognitive impairment could not be established in the study because no formal neuropsychological testing was performed to confirm diagnosis.

References
  • Dong, Y.H., Sharma, V.K., Chan, B.P.L., Venketasubramanian, N., Teoh, H.L., Seet, R.C.S., Tanicala, S., Chan, Y.H. & Chen, C. (2010). The Montreal Cognitive Assessment (MoCA) is superior to the Mini-Mental State Examination (MMSE) for the detection of vascular cognitive impairment after acute stroke. Journal of Neurological Sciences. doi:10.1016/j.jns.2010.08.051
  • Koski, L., Xie, H. & Finch, L. (2009). Measuring cognition in a geriatric outpatient clinic: Rasch analysis of the Montreal Cognitive Assessment. Journal of Geriatric Psychiatry and Neurology, 22, 151-160.
  • Luis, C.A, Keegan, A.P. & Mullan, M. (2009). Cross validation of the Montreal Cognitive Assessment in community dwelling older adults residing in the Southeastern US. International Journal of Geriatric Psychiatry, 24, 197-201.
  • Nasreddine, Z. S., Phillips, N. A., Bediriam, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53, 4, 695-699.
  • Nasreddine, Z. S., Chertkow, H., Phillips, N., Whitehead, V., Collin, I., Cummings, J. L. The Montreal Cognitive Assessment (MoCA): A brief cognitive screening tool for detection of mild cognitive impairment. Neurology, 62(7): S5, A132. Presented at the American Academy of Neurology Meeting, San Francisco, May 2004.
  • Nasreddine, Z. S., Chertkow, H., Phillips, N., Whitehead, V., Bergman, H., Collin, I., Cummings, J. L., Hébert, L. The Montreal Cognitive Assessment (MoCA): a Brief Cognitive Screening Tool for Detection of Mild Cognitive Impairment. Presented at the 8th International Montreal/Springfield Symposium on Advances in Alzheimer Therapy. http://www.siumed.edu/cme/AlzBrochure04.pdf p. 90, April 14-17, 2004.
  • Nasreddine, Z. S., Collin, I., Chertkow, H., Phillips, N., Bergman, H., Whitehead, V. Sensitivity and Specificity of The Montreal Cognitive Assessment (MoCA) for Detection of Mild Cognitive Deficits. Can J Neurol Sci, 30 (2), S2, 30. Presented at Canadian Congress of Neurological Sciences Meeting, Québec City, Québec, June 2003.
  • Pendlebury, S.T., Cuthbertson, F.C., Welch, S.J.V., Mehta, Z. & Rothwell, P.M. (2010). Underestimation of cognitive impairment by Mini-Mental State Examination versus the Montreal Cognitive Assessment in patients with transient ischemic attack and stroke. Stroke, 41, 1290-1293.
  • Smith, T., Gildeh, N. & Holmes, C. (2007). The Montreal Cognitive Assessment: Validity and utility in a memory clinic setting. The Canadian Journal of Psychiatry, 52, 329-332.
  • Wittich, W., Phillips, N., Nasreddine, Z.S. & Chertkow, H. (2010). Sensitivity and specificity of the Montreal Cognitive Assessment modified for individuals who are visually impaired. Journal of Visual Impairment & Blindness, 104(6), 360-368.