Montreal Cognitive Assessment (MoCA)

Evidence Reviewed as of before: 20-01-2011
Author(s): Lisa Zeltzer, MSc OT; Katie Marvin, MSc PT Candidate
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

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.

In-Depth Review

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.

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.
  • The MoCA is suitable for any individual who is experiencing memory difficulties but who scores within the normal range on the Mini-Mental State Examination.

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.

Summary

What does the tool measure? Mild cognitive impairment
What types of clients can the tool be used for?

Can be used with but not limited to:

  • patients with stroke
  • any individual who is experiencing memory difficulties but scores within the normal range on the Mini Mental State Examination.
Is this a screening or assessment tool? Screening
Time to administer The MoCA takes approximately 10-15 minutes to administer for clients with mild cognitive impairment.
Versions MoCA (original); MoCA English (version 2); and MoCA English (version 3); MoCA (modified for individuals with visual impairments).
Other Languages 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.
Measurement Properties
Reliability
  • Only 1 study has examined the internal consistency of the MoCA and reported excellent levels of internal consistency.
  • Only 1 study has examined the test-rest reliability of the MoCA, and reported excellent test-retest.
  • No studies have examined the inter-rater reliability of the MoCA.
  • No studies have examined the intra-rater reliability of the MoCA.
Validity

Criterion:

Concurrent:

Excellent correlations with the Mini Mental State Examination (MMSE) have been reported.

Construct:

Known groups:

One study reported that the MoCA can distinguish between patients with mild cognitive impairment and healthy controls.

Floor/Ceiling Effects No studies have examined the ceiling or floor effects of the MoCA.
Does the tool detect change in patients? Not Applicable.
Acceptability The MoCA is not suitable for individuals with aphasia or for use with a proxy respondent
Feasibility The measure is simple to score and only the MoCA test sheet and a pencil are required to complete the measure.
How to obtain the tool? The MoCA is available at: http://www.mocatest.org.

Psychometric Properties

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.

See The Measure

How to obtain the MoCA?

The MoCA is available at: http://www.mocatest.org.

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