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RehabMeasures Instrument

Montreal Cognitive Assessment

Last Updated

Purpose

Rapid screen of cognitive abilities designed to detect mild cognitive dysfunction.

Link to Instrument

instrument details

Acronym MoCA

Cost

Free

Diagnosis/Conditions

  • Cardiac Dysfunction
  • Parkinson's Disease + Neurologic Rehabilitation
  • Stroke Recovery

Key Descriptions

  • 16 items and 11 categories to assess multiple cognitive domains (e.g., visuo-spatial and executive functions, naming, memory, attention, language, abstraction, and orientation).
  • Visuo-spatial / Executive: Alternating trail making, (visuo-constructive skills with cube or other figure, viscuo-constructive skills with clock)
  • Naming: Animals
  • Memory: Introduce word list and delayed recall
  • Attention: Forward digit span, backward digit span, vigilance, serial 7's
  • Language: Sentence repetition and verbal fluency
  • Abstraction: Recognize similarity
  • Orientation: Recall place and date
  • Total possible total score = 30
  • Scoring criteria are provided for each category/item. Three different forms of the test are available to reduce likelihood of practice effects.
  • Test manual (directions, scoring instructions) and score sheets are available at website www.mocatest.org

Number of Items

16

Equipment Required

  • Score Sheet
  • Stop Watch
  • Pencil
  • Paper

Time to Administer

10 minutes

Required Training

Reading an Article/Manual

Instrument Reviewers

Initially reviewed by Karen McCulloch, PT, PhD, NCS and the TBI Edge task force of the Neurology Section of the APTA in 10/2012; Erin Hussey, DPT, MS, NCS and the PD Edge task force of the Neurology Section of the APTA in 2013.

ICF Domain

Body Structure
Body Function

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations Based on Parkinson Disease Hoehn and Yahr stage: 

 

I

II

III

IV

V

PD EDGE

HR

HR

HR

HR

LS/UR

 

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

NR

LS

NR

LS

NR

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

PD EDGE

Yes

Yes

Yes

Not reported

TBI EDGE

No

Yes

Yes

Not reported

Considerations

  • Chou et al, 2010 reported task force recommendation (based on review of 353 published articles) was to use MoCA over several other cognitive assessment screens (MMSE, MMP, PANDA, and SCOPA-cog) for detection of MCI in those with PD when cognition is not a primary outcome measure.
  • The MoCA has been extensively used and studied in older adult populations and in PD where cognitive impairment is problematic. 

  • This review is not exhaustive, but focused on initial development of the measure and its use with persons with stroke to determine possible appropriateness of the measure for use with TBI. 

  • The MoCA has a greater emphasis on attention and executive function than the MMSE that is commonly used to screen for cognitive impairments. 

  • For those with mild deficits, the MoCA appears to be more sensitive for those with high premorbid IQ, non-AD dementia and early stages of dementia. 

  • There are multiple parallel versions of the MoCA, an advantage when it might be used more than once with a partient. 

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Alzheimer's Disease and Progressive Dementia

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Cut-Off Scores

Cognitive Impairment

(Nasreddine et al, 2005) 

  • A score of 26 or above is considered normal

  • For individuals with 12 years or fewer of formal education, one point is added to the score as a correction

Sensitivity and Specificity (%) MoCA and MMSE

 

 

 

Cut-off

>26

<26

<26

Group (n)

Normal Controls (90)

Mild Cognitive Impairment (94)

Alzheimer's Disease (93)

MoCA

87

90

100

MMSE

100

18

78

Cognitive Impairment

(Smith et al, 2007; From a population in a memory clinic: 32 subjects diagnosed with dementia; 23 subjects with mild cognitive impairment; 12 comparison subjects; mean age 73.6 (10) years; mean MMSE score at baseline 27.4 (1.6);mean MoCA score 22.3 (3.6)) 

 

Sensitivity (95% CI)

 

Specificity (95% CI)

 

Test

MMSE

MoCA

MMSE

MoCA

MCI

0.17 (0.08-0.34)

0.83 (0.66-0.92)

1.00 (0.82-1.0)

0.50 (0.29-0.72)

dementia

0.25 (0.15-0.39)

0.94 (0.83-0.98)

1.00 (0.82-1.00)

0.50 (0.29-0.72)

  • The MoCA had better sensitivity (100%) identifying subjects with MCI who were diagnosed with dementia at a six month followup, than the MMSE with sensitivity of 25%. 

 

Normative Data

Cognitive Impairment

(Nasreddine et al, 2005 and mocatest.org website)

MoCA Items Average Scores

 

 

 

 

NC

MCI

AD

Trails

0.87 (0.34)

0.56 (0.50)

0.27 (0.45)

Cube

0.71 (0.46)

0.46 (0.50)

0.25 (0.43)

Clock

2.65 (0.65)

2.16 (0.82)

1.56 (0.98)

Naming

2.88 (0.36)

2.64 (0.58)

2.19 (0.82)

Memory

3.73 (1.27)

1.17 (1.47)

0.52 (1.03)

Digit Span

1.82 (0.44)

1.83 (0.43)

1.49 (0.62)

Letter A

0.97 (0.18)

0.93 (0.26)

0.67 (0.47)

Serial 7

2.89 (0.41)

2.65 (0.65)

1.82 (1.12)

Sentence Rep

1.83 (0.37)

1.49 (0.71)

1.37 (0.80)

Fluency F

0.87 (0.34)

0.71 (0.45)

0.32 (0.47)

Abstraction

1.83 (0.43)

1.43 (0.68)

0.99 (0.80)

Orientation

5.99 (0.11)

5.52 (0.84)

3.92 (1.73)

Total*

27.37 (2.20)

22.12 (3.11)

16.16 (4.81)

*Total is adjusted for education

 

 

 

Test/Retest Reliability

Older adults with MCI and AD:

(Nasreddine et al, 2005; = 94 with MCI, mean age 75.2 (6.3) years; mean 12.28 (4.3) years of education; = 93 patients with AD, mean age = 76.7 (8.8) years; mean 10.03 (3.8) years of education; = 90 healthy controls; mean age 72.8 (7.0) years; mean 13.3 (3.4) years of education)

  • Excellent test retest reliability (= 0.92) with subgroup of 26 patients with cognitive impairment tested on average 35.0 (17.6) days apart

  • Mean change in scores =  0.9 + 2.5 points

Internal Consistency

Older adults with MCI and AD:

(Nasreddine et al, 2005)

  •  Excellent internal consistency (a = 0.83)

Construct Validity

Older adults with MCI and AD:

(Nasreddine et al, 2005) 

  • Total scores and majority of items differentiated between known groups of healthy controls, individuals with MCI and AD 
  • All items differentiated between at least two of the groups

Face Validity

  • Was developed based on clinical intuition of first author and clinical testing over a five year period prior to validation study in 2005 (Nasreddine et al, 2005)

Parkinson's Disease

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Cut-Off Scores

Parkinson's Disease:

(Dalyrimple-Alford et al, 2010; = 114 PD and 47 controls; median duration PD motor symptoms 12.5, (1-30) years. 3 groups identified as PD-N (normal cognition, = 72, disease duration 4.6 (3.9), HY stage 1.9 (0.9)], PD-MCI (mild cognitive impairment, = 21, disease duration 7.3 (5.2), Mean HY 2.6 (0.9)]and PD-D [dementia, = 21, disease duration 12.6 (8.1); H&Y stage mean = 3.4 (0.8)]. 

  • MoCA screening cutoff for PD-MCI < 26/30 (SN 90%, SP 75%; AUC 90%; 95% CI 82-95%, NPV = 92%) 
  • MoCA best at differentiating PD-MCI
    • MoCA vs SCOPA-Cog (AUC difference of 12%, p < 0.05) 
    • MoCA vs MMSE-sevens (AUC difference 12%; p < 0.05) 
  • MoCA screening cutoff for PD-D = 21/30 (SN 81%, SP 95%, AUC 97%; 95% CI 92-99%, NPV = 95%) 
    • MoCA vs MMSE-world (AUC difference 10%, p < 0.05) 
    • MoCA, MMSE, and SCOPA-COG, All 3 accurately discriminated for PD-D without statistical distinction on ROC values between measures

(Hoops et al, 2009; = 132 with idiopathic PD; 75.8% male; 94.7% white; mean age 65.1 (9.7); PD duration 6.5 (5.3); Education level = 16.4 (3.1) years. 30% determined to have cognitive disorder using Dementia criteria: > 1.5 SD below normative mean in at least 2 of 4 cognitive domains, self-report of cognitive dysfunction, and cognition interfering with IADL. PD-Norm (= 92): H&Y stage 1: 50%, 2: 41.3% 3: 7.6% 4: 1.1%; GDS-15 3.0 (3.4), (= 40) PD-MCI and PD-D (= 40): H&Y stage 1 = 17.5%, 2 = 62.5%, 3 = 15.0%, 4 = 2.5%, 5 = 2.5%; GDS-15 score 4.3 (4.0). 

  • MoCA cutoff for any cognitive disorder (MCI or D) = 26/30 (sensitivity = 0.90, specificity = 0.53). PPV = 46; NPV = 92, and 64% accuracy. 
  • In comparison, cutoff for MMSE = 29/30 (SN 0.9, SP 0.38), PPV = 0.39 and 54% accuracy 

(Robben et al, 2010; = 41; Young group (< 66, = 22. PDD, = 5, HY stages [%]: 1 = 7, 2 = 12, 3 = 3) Older group (> 65, = 19, PDD = 10; HY stages [%]: 2 = 6, 3 = 6, 4 = 6, 5 = 1). Prospective study; Blinded examiner. Questionnaire, MoCA, FAB, ACE-R) 

  • MoCA cutoff for PD-Dementia = 22/30 for the older group. (SN 100%, SP 100%, AUC (95% CI) = 1.0 (1.0-1.0) and 23/30 for PDD young group (SN 80%, SP 88.2%, AUC (95% CI) = 0.81 (0.58-1.0). Scores on MoCA, FAB, and ACE-R significantly lower in PDD young group (MW U: p < 0.05) Scores on MoCA, FAB, and ACE-R significantly lower in PDD older group (MW-U: p < 0.01) 
  • MoCA did not show a false negative result but did take longer to administer (~16 min) than FAB and ACE-R. 
  • Recommended sequence: 1) questionnaire, if positive, follow-up with 2) Screening with MoCA or other screening measure, if positive, followup with 3) full Neuropsychologic Exam assessment battery

Normative Data

Parkinson Disease:

(Hoops et al, 2009)

  • PD norm = MoCA score 26.2 (2.9); MMSE score 28.7 (1.5), 
  • PD-MCI and PD-D = MoCA score 22.2 (4.1); MMSE score 26.8 (2.3)

(Gill et al, 2008; = 38 (17.5% female); mean age = 71.3 (10.5) yrs, Education 14.8 (3.1) yrs, , H&Y stage 2.9 (0.94), Schwab and England 79% (12), Symptom duration 6.6 (5.4) yrs, Geriatric Depression Scale 1.9 (1.3)) 

  • MoCA displays lower scores across progressive disease stages and wider range of scores than MMSE. Range of scores: 6-28 for MoCA, while MMSE range was 16-30
  • Mean MoCA score of 23.3 (2.1) was significantly lower than mean MMSE score of 27.4 (1.9) for this group (p < 0.01) 
    • HY Stages 1-2: Mean MoCA = 23.3 (4.1); MMSE = 27.6 (2.5) 
    • HY stage 3: mean MOCA = 21.2 (4.8) ; MMSE = 26.9 (3.5) 
    • HY stages 4-5: Mean MoCA = 19.9 (4.3); MMSE = 25.4 (3.0)

Test/Retest Reliability

Parkinson's Disease:

(Gill et al, 2008) 

  • Excellent test-retest reliability (= 8): ICC = 0.79 (95% CI: 0.36–1.2); Tested on average 133 days apart

Interrater/Intrarater Reliability

Parkinson's Disease: 

(Gill et al, 2008) 

  • Excellent interrater reliability (= 11): ICC = 0.81 (95%, CI: 0.41–1.2); tested on average 129 days apart

Criterion Validity (Predictive/Concurrent)

Parkinson's Disease: 

(Gill et al, 2008) 

  • Excellent correlation with neuropsychologic battery ICC = 0.72 (< 0.0001). Neuropsychology Battery included Hopkins Verbal Learning Test-Revised, the Letter Number Sequencing subtest of the Wechsler Adult Intelligence Scale, the Comalli–Kaplan adaptation of the Stroop, and the Phonemic and Category Verbal Fluency tests 
  • Excellent correlation between MMSE and MoCA ICC = 0.66 (< 0.0001)

Construct Validity

Parkinson's Disease: 

(Dalyrimple et al, 2010) 

  • Poor correlation with premorbid IQ (= 0.19; < 0.05) 

(Nazem et al, 2009): N = 100 with idiopathic PD (70% male, 96% white); Age 65.3 (11.5); Education level 15.7 (3.6) years; disease duration 7.7 (6.4) years; median Hoehn & Yahr stage = 2; mean GDS-15 score 3.4 (3.8) (26% showing clinically sig depression); evaluated “on” medication state; 19% with DBS; intact global cognition (MMSE > 25; in top 75th percentile when adjusted for age & education)

  • Despite normal MMSE scores (> 25), 52% scored positive for cognitive impairment on MoCA (< 26) indicating greater potential sensitivity of MoCA. 
  • Association between MoCA and UPDRS (Odds Ratio 1.07 (95% CI = 1.02–1.11) p = 0.006 was determined to be due to the motor items of the MoCA. 
  • Regression analysis demonstrated: Poor correlation MoCA (visuospatial and executive subscores) and UPDRS motor score (r = -0.14, p = 0.17)

Floor/Ceiling Effects

Parkinson's Disease: 

(Hoops et al, 2009) 

  • There was no ceiling effect for MoCA but there was ceiling effect for MMSE. MoCA results involved larger range of scores with 19-point spread (12-30) while the MMSE range was narrower at 9-point spread (22-30) 

(Zadikoff et al, 2008; = 88 (M: 62, F: 26); mean age = 65 +/-10 yrs; mean disease duration 9.5 (5) years; mean UPDRS III 20.7 (11.6); Education level identified for adjustment; Tested “on” med status; Tested using combined version of MoCA and MMSE using cutoff of 26 for each measure) 

  • MoCA demonstrated less of a ceiling effect when compared to the MMSE (when controlled for educational level). 
  • More subjects scored < 26 on MoCA than on MMSE (x= 22.5, < 000002) 
  • If subject scored > 25 on MoCA, they did not score < 26 on the MMSE. 
  • In contrast, 36% of those who scored >25 on MMSE had score of <26 on MoCA (< 0.0001)

Non-Specific Patient Population

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Cut-Off Scores

Heart Disease

(Rossetti et al, 2011; n = 2653; mean age 50.03, range 18-85; sample from Dallas Heart Study incorporating multiple ethnicities: 25% Caucasian, 52% African-American, 11% Hispanic)

  • Suggests the cut-off score recommended by developers may be too low, since 62% of the sample would be classified with cognitive impairment even with points added based on years of education.

  • Normative values provided in study may be a better guide for performance especially for different ethnic backgrounds.

Normative Data

Normative sample:

(Rossetti et al, 2011) 

MoCA Score by Age and Education Level

 

 

 

 

 

 

 

 

 

Years of Education

 

 

 

 

 

 

 

 

<12

 

12

 

 

 

>12

 

 

 

Total by age

 

Age group, y

No.

Mean(SD)Median

No

Mean(SD)Median

No

Mean(SD)Median

No

 

Mean(SD)

<35

20

22.8(3.38)23

65

24.46(3.49)25

122

25.93(2.48)26

207

25.16(3.08)

30-40

37

22.84(3.18)23

106

23.99(2.93)24

264

25.81(2.64)26

408

25.07(2.95)

35-45

55

22.11(3.33)23

177

23.02(3.67)24

355

25.38(3.05)26

588

24.37(3.51)

40-50

77

21.36(3.73)22

227

22.26(3.94)23

418

25.09(3.16)26

723

23.80(3.80)

45-55

77

20.75(3.80)21

216

21.87(3.95)22

461

24.70(3.24)25

755

23.48(3.84)

50-60

62

19.94(4.34)20

172

22.25(3.46)22

424

24.34(3.38)25

659

23.37(3.78)

55-65

60

19.60(4.14)20

143

21.58(3.93)22

369

24.43(3.31)25

573

23.20(3.96)

60-70

57

19.30(3.79)19

113

20.89(4.50)21

246

24.32(3.04)25

418

22.69(4.12)

65-75

38

18.37(3.87)19

67

20.57(4.79)21

122

24.00(3.35)24

228

22.05(4.48)

70-80

14

16.07(3.17)17

23

20.35(4.91)20

42

23.60(3.47)24

79

21.32(4.78)

Total by education

230

20.55(4.04)21

608

22.34(3.97)23

1306

24.81(3.20)25

2148

23.65(3.84)

 

Stroke

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Internal Consistency

Subacute mild stroke

(Toglia et al, 2011; = 72; mean age 70 (17) years; 8.5 days post-stroke with mild neurological (NIHSS 4) and cognitive (MMSE median 25) deficits)

  • Excellent internal consistency (Chronbach’s alpha = 0.78)

  • Higher internal consistency than MMSE (a = 0.60)

Criterion Validity (Predictive/Concurrent)

Subacute mild stroke:

(Toglia et al, 2011)

  • Excellent correlation of MoCA with MMSE (= 0.79) and Cognitive FIM scores (= 0.67)

  • Adequate correlation with discharge status (= 0.40), which is higher than MMSE (r = 0.30)

  • Stronger relationship of MoCA scores to rate of functional improvement (formula using admission and discharge FIM scores, LOS) than the MMSE

  • MoCA visuoexecutive subscore was strongest predictor of functional status and improvement in FIM scores

Floor/Ceiling Effects

Subacute mild stroke:

(Toglia et al, 2011)

  • Identified more patients as having cognitive impairment than usual cutoff points for MMSE (89% vs. 63%)

  • Attributed to greater ceiling effects with MMSE

  • Mean scores for delayed recall, visuoexecutive and verbal fluency were all < 50% of maximum score

Bibliography

Chou, K. L., Amick, M. M., et al. (2010). "A recommended scale for cognitive screening in clinical trials of Parkinson's disease." Movement Disorders 25(15): 2501-2507.

Dalrymple-Alford, J., MacAskill, M., et al. (2010). "The MoCA Well-suited screen for cognitive impairment in Parkinson disease." Neurology 75(19): 1717-1725.

Gill, D. J., Freshman, A., et al. (2008). "The Montreal cognitive assessment as a screening tool for cognitive impairment in Parkinson's disease." Mov Disord 23(7): 1043-1046.

Hoops, S., Nazem, S., et al. (2009). "Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease." Neurology 73(21): 1738-1745.

Nasreddine, Z. S., Phillips, N. A., et al. (2005). "The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment." Journal of the American Geriatrics Society 53(4): 695-699.

Nazem, S., Siderowf, A. D., et al. (2009). "Montreal Cognitive Assessment Performance in Patients with Parkinson's Disease with “Normal” Global Cognition According to Mini‐Mental State Examination Score." Journal of the American Geriatrics Society 57(2): 304-308.

Robben, S. H., Sleegers, M. J., et al. (2010). "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 25(3): 258-265.

Rossetti, H. C., Lacritz, L. H., et al. (2011). "Normative data for the Montreal Cognitive Assessment (MoCA) in a population-based sample." Neurology 77(13): 1272-1275.

Smith, T., Gildeh, N., et al. (2007). "The Montreal Cognitive Assessment: validity and utility in a memory clinic setting." Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 52(5): 329-332.

Toglia, J., Fitzgerald, K. A., et al. (2011). "The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute stroke: relationship to functional outcome." Archives of Physical Medicine and Rehabilitation 92(5): 792-798.

Zadikoff, C., Fox, S. H., et al. (2008). "A comparison of the mini mental state exam to the Montreal cognitive assessment in identifying cognitive deficits in Parkinson's disease." Mov Disord 23(2): 297-299. 

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