Montreal Cognitive Assessment (MoCA) Debbie Froese, B.M.R.-O.T., B.A. Christine Knight, Ph.D.,R.Psych.

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1 Montreal Cognitive Assessment (MoCA) Debbie Froese, B.M.R.-O.T., B.A. Christine Knight, Ph.D.,R.Psych. Community Geriatric Mental Health

2 Model of Continuum of Cognition with Aging Normal Mild cognitive impairment Function Probable AD Dementia Definite AD / Dementia Age

3 Cognitive Impairment A cognitive impairment is an abnormal change in how a person thinks, emotionally responds, or behaves. It may involve changes in one or more domains including Orientation Attention Memory Language Visual-spatial Executive functions Judgment & insight Ability to perform ADLs & IADLs

4 Reasons why someone s cognition may be worse than expected Most common causes of cognitive impairment Delirium (acute, reversible) Depression (chronic, usually reversible) Dementia (chronic, irreversible) But also, it may be: Medications, especially sedatives Medical illness (e.g. thyroid problems) Alcohol Other neurological conditions (Parkinsons, MS, brain tumors) Mild Cognitive Impairment

5 Dementia Defined demens - without mind An acquired syndrome characterized by multiple cognitive deficits, including memory impairment and at least one of: aphasia apraxia agnosia executive functions that causes significant impairment in functioning and ADLs and represents a decline from a previously higher level of function.

6 Mild Cognitive Impairment (MCI) Petersen Criteria (1999): Memory complaint (subjective) Abnormal memory for age (objective) Normal general cognitive function Normal activities of daily living (IADLs) Not meeting criteria for dementia

7 MCI Revisited Cognitive decline greater than expected for an individual s age and education level, but that does NOT interfere notably with activities of daily life. Amnestic MCI Non-Amnestic Single Domain MCI Multi-Domain MCI MCI is a high-risk condition which may progress to dementia. Amnestic MCI has been found to progress at a predictable annual rate of ~ 12% to Alzheimer Disease.

8 Goals of Cognitive Screening To determine if cognition is normal: Reassure patient and family members To determine if cognition is not normal: Need for further cognitive assessment All memory complaints should be evaluated and the individual followed To assess progression Should be considered very seriously when confirmed by caregiver/informant If cognition is not normal, possibilities include.

9 Screening for MCI with MMSE Using a cutoff of 24/30 Low sensitivity (30-60%) - means failure to reveal deficits in approximately half of patients in the early stage of dementia. High specificity (92-100%) means that most patients who score above 24 really don t have dementia Galasko, D., Klauber, M.R., & Hofsetter, C.R. (1990). The Mini-Mental State Examination in the early diagnosis of Alzheimer Disease. Arch Neurol, 47:49-52

10 Rationale for MoCA Most individuals meeting clinical criteria for MCI score above 26 on the MMSE, which is also the range for normal elderly. Nasreddine et al (2005) developed the MoCA to be a highly sensitive and specific screening tool for detecting MCI Sensitivity is increased by inclusion of more demanding tasks, including also tests of: executive functioning delayed memory higher level language abilities more complex visual-spatial processing tasks Result = 30 point instrument that can be administered in 10 minutes. Score < 26 = abnormal

11 MMSE score Psychometric Evaluation MoCA vs. MMSE in DAT, MCI's and Normals DAT MCI ENC MoCA score

12 Sensitivity of the MoCA and MMSE 26 NORMAL MoCA 87% MMSE 100% SCORE < 26 MCI MoCA 90% MMSE 18% < 26 AD MoCA 100% MMSE 78% Using a cut-off score <26 provides sensitivity of 90%, and specificity of 87% to distinguish MCI from normal

13 Screening for Cognitive Impairment MMSE Recommended to be administered first if there are clear cognition concerns and some functional changes to daily living activities. If their MMSE is normal (>=26), administer the MoCA next. MoCA Recommended to be administered first if there are cognitive complaints but no functional changes. The MoCA is more sensitive than MMSE to differentiate MCI from normal cognition and from early dementia

14 Forms and instructions available at

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