Montreal Cognitive Assessment
Encyclopedia
The Montreal Cognitive Assessment, MoCA, was created in 1996 (Copyright: Dr Z. 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).
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.
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 tumor
s (including high and low grade glioma
s), 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.
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).
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
English language
English is a West Germanic language that arose in the Anglo-Saxon kingdoms of England and spread into what was to become south-east Scotland under the influence of the Anglian medieval kingdom of Northumbria...
, 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
Lion
The lion is one of the four big cats in the genus Panthera, and a member of the family Felidae. With some males exceeding 250 kg in weight, it is the second-largest living cat after the tiger...
, camel
Camel
A camel is an even-toed ungulate within the genus Camelus, bearing distinctive fatty deposits known as humps on its back. There are two species of camels: the dromedary or Arabian camel has a single hump, and the bactrian has two humps. Dromedaries are native to the dry desert areas of West Asia,...
, rhinoceros
Rhinoceros
Rhinoceros , also known as rhino, is a group of five extant species of odd-toed ungulates in the family Rhinocerotidae. Two of these species are native to Africa and three to southern Asia....
; 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 diseaseAlzheimer's disease
Alzheimer's disease also known in medical literature as Alzheimer disease is the most common form of dementia. There is no cure for the disease, which worsens as it progresses, and eventually leads to death...
compared with the well-known Mini-Mental State Examination
Mini-mental state examination
The mini–mental state examination or Folstein test is a brief 30-point questionnaire test that is used to screen for cognitive impairment. It is commonly used in medicine to screen for dementia...
(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 diseasesNeurological disorder
A neurological disorder is a disorder of the body's nervous system. Structural, biochemical or electrical abnormalities in the brain, spinal cord, or in the nerves leading to or from them, can result in symptoms such as paralysis, muscle weakness, poor coordination, loss of sensation, seizures,...
that affect younger populations, such as Parkinson's disease
Parkinson's disease
Parkinson's disease is a degenerative disorder of the central nervous system...
(5 studies showing the superiority of the MoCA over the MMSE), vascular cognitive impairment
Vascular cognitive impairment
Vascular cognitive impairment is a term used to describe a spectrum of cognitive impairments caused by various types of cerebrovascular disease that occurs as a result of interaction between a variety of vascular risk factors such as hypertension, obesity, dyslipidemia, diabetes mellitus, stroke...
, Huntington's disease
Huntington's disease
Huntington's disease, chorea, or disorder , is a neurodegenerative genetic disorder that affects muscle coordination and leads to cognitive decline and dementia. It typically becomes noticeable in middle age. HD is the most common genetic cause of abnormal involuntary writhing movements called chorea...
, brain metastasis
Brain metastasis
A brain metastasis is a cancer that has metastasized to the brain from another location in the body. Brain metastases are the most common cause of intracranial mass lesions, and up to 45% of cancer patients eventually develop brain metastases during the course of their illness, with 98,000 to...
, primary brain tumor
Brain tumor
A brain tumor is an intracranial solid neoplasm, a tumor within the brain or the central spinal canal.Brain tumors include all tumors inside the cranium or in the central spinal canal...
s (including high and low grade glioma
Glioma
A glioma is a type of tumor that starts in the brain or spine. It is called a glioma because it arises from glial cells. The most common site of gliomas is the brain.-By type of cell:...
s), and multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...
, and other conditions, such as traumatic brain injury
Traumatic brain injury
Traumatic brain injury , also known as intracranial injury, occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism , or other features...
, depression, schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
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
Education
Education in its broadest, general sense is the means through which the aims and habits of a group of people lives on from one generation to the next. Generally, it occurs through any experience that has a formative effect on the way one thinks, feels, or acts...
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.
Recommendation
The MoCA has been recommended by:The National Institutes of Health
National Institutes of Health
The National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...
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).