Montreal Cognitive Assessment (MoCA) Test for Dementia

The Montreal Cognitive Assessment (MoCA) is a test used to detect mild cognitive decline and early signs of dementia. It can help identify people at risk of Alzheimer's disease and screen for conditions like Parkinson's disease, brain tumors, substance abuse, and head trauma.

Introduced in 2005, the MoCA test is an update from the older Mini-Mental State Examination (MMSE) introduced in 1975. It contains 30 questions and takes 10 minutes to complete. While the MOCA test is useful in detecting dementia, it cannot differentiate between the different dementia types.

There are advantages and disadvantages of this important screening tool. On the one hand, it is simple and quick to administer; on the other, training is needed to properly administer the test, and a person's education level can influence the results.

Purpose of the MoCA Test

The MoCA test is a simple, in-office tool that can quickly determine if there is any impairment in a person's cognitive function, including their ability to understand, reason, and remember.

The test is used for adults 55 to 85 with early signs of dementia (the progressive loss of intellectual functioning, especially memory and abstract thinking).

If the test indicates that a person has mild cognitive impairment (MCI), additional evaluations may be done to check for suspected causes, like:

• Alzheimer's disease
• Parkinson's disease
• Vascular dementia
• Lewy body dementia
• Frontotemporal lobe dementia
• Huntington's disease
• Brain tumors (both benign and cancerous)
• Brain metastases (the spread of cancer to the brain)

The MoCA test can also check for MCI in people with known conditions such as:

• Traumatic brain injury
• Stroke
  
• Multiple sclerosis
• Schizophrenia

How the MoCA Works

The MoCA test is based on scores with a maximum score of 30. It takes 10 to 12 minutes to complete.

The MoCA test examines seven domains (aspects) of cognitive function with a total of 11 different exercises and tasks:

1. Executive and visuospatial function: You will first be given a picture with numbered dots (1, 2, 3, 4, 5) and lettered dots (A, B, C, D, E) and asked to connect them sequentially, alternating numbers and letters. Next, you will be given a drawing of a three-dimensional cube and asked to make a copy. Finally, you will be asked to draw a dial clock that reads 10 minutes past 11:00. 
2. Naming: You will be shown pictures of three animals and asked what type of animal they are.
3. Attention: You will first be given a series of numbers and asked to repeat them forward or backward. You will then be given a series of letters and asked to pick out the letter "A." Finally, you will be given several numbers and asked to subtract them from 100.
4. Language: You will first be asked to repeat back two different sentences verbatim. You will then be shown a series of capital letters and asked to pick out all of the "As."
5. Abstraction: You will be asked what is in common between two different things (such as an apple and an orange, or a car and an airplane),
6. Delayed recall: You will be given five words and asked to repeat them back after five minutes.
7. Orientation: You will be asked about the date, month, year, day, city, and place you are in. 

MoCA vs. MMSE

The MoCA is similar to an older test called the Mini-Mental State Exam (MMSE). Both tests use a 30-point scale and take only a few minutes to complete. 

Both the MoCA and MMSE have their benefits, limitations, and uses:

• MOCA: This test is better at distinguishing between normal cognition and MCI. The test is harder than the MMSE and less informative in people with moderate to severe dementia as their ability to complete the task rapidly falls away. The MoCA is used primarily for the early detection of dementia.
• MMSE: This test is better for people with known dementia. Because it is less difficult, it can detect subtle changes in cognition even if certain domains are unaffected. (For instance, a highly educated person might still have high executive function but be unable to recall the names of their grandkids.) Because of this, the MMSE is better suited to monitor the decline in cognition.

On their own, neither test can diagnose the cause of cognitive impairment or dementia.

Scoring the MoCA Test

The total score on the MoCA test ranges from 0 to 30. The scoring per domain is broken downs as follows:

Because a person's education can limit their comprehension of certain tasks, 1 point is added to the total score if a person has 12 years or less of formal education. 

Interpreting the Results

After tallying the MoCA scores, the results can be interpreted as follows:

Advantages vs. Disadvantages

Among the advantages of the MoCA test:

• It is simple and brief.
• It has a high sensitivity for mild cognitive impairment.
• It is an objective test that is less vulnerable to subjective interpretation.
• It is available in more than 35 languages as well as versions for people with blindness or hearing impairment.
• Unlike the MMSE, it is not copyrighted and therefore free for non-profit use.

Among the disadvantages of the MoCA test:

• Training is needed for the test to be administered and scored correctly.
• A person’s education level can influence the results. (Poverty can also influence the results as it is linked to lower educational status.)
• Certain mental health problems can skew the results and lead to incorrect findings. People with depression, for example, often score lower without having actual cognitive impairment.
• The test cannot determine which type of dementia is involved.

How Accurate Is the MoCA Test?

The MoCA test is generally better at detecting MCI and early dementia than the MMSE test. This is based on comparisons of the sensitivity (the ability to correctly identify people with a disease) and specificity (the ability to correctly identify people without a disease) of both tests.

A 2015 study published in BMC Geriatrics reported that the MoCA has a sensitivity and specificity of 90% and 87% respectively in detecting MCI. By contrast, the MMSE has a sensitivity and specificity of 18% and 100%. The MMSE was only better at detecting when someone doesn't have MCI.

Alternatives to the MoCA Test

The MoCA test is one of the most widely used tests for detecting dementia, but there are others that are sometimes used to detect mild neurocognitive impairment and the early signs of dementia.

SLUMS Examination

The Saint Louis University Mental Status (SLUMS) Examination is a screening test for Alzheimer's disease and other kinds of dementia. It is an alternative to the more widely used MoCA and MMSE and consists of 11 questions that help a healthcare provider evaluate skills like:

• Orientation to time and place
• Short-term memory
• Simple math calculations
• Naming of animals
• Clock drawing test
• Recognition of geometric figures

The various questions are scored from 0 to 5, with a maximum score of 30. A score of 0 to 20 indicates dementia, while a score of 21 to 26 indicates mild neurocognitive impairment. Anything over 26 is considered normal.

Studies have shown that the SLUMS test has a similar reliability to the MoCA in detecting early signs of dementia. Others suggest that it may be far superior to the MMSE in doing the same.

The SLUMS test has also proven superior to the MoCA and MMSE in the detection of cognitive impairment in people with a traumatic brain injury (TBI). Because the SLUMs test is slightly more demanding (requiring basic math skills), it may be more sensitive to changes outside of the realm of aging-associated conditions like Alzheimer's.

ADAS-Cog Test

The Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) is used to diagnose the severity of dementia in people already diagnosed with dementia. The ADAS-Cog is the standard most commonly used in clinical trials and is considered the gold standard for assessing a person's response to Alzheimer's treatments.

The ADAS-Cog consists of 11 parts that assess skills like:

• Word finding, recall, recognition, and comprehension
• Orientation to time and place
• Naming objects
• Following and remembering directions
• Copying geometric patterns
• Completing a sequence of tasks

The various questions are scored from 1 to 5, with a maximum score of 70. Higher scores indicate worse cognitive dysfunction. Scores of at least 18 indicate cognitive impairment.

The ADAS-Cog requires high levels of training for the results to be qualitative.

SPMSQ Tool

The Short Portable Mental Status Questionnaire (SPMSQ) is a simple test that doesn't require any writing or drawing. It can be administered anywhere and consists of 10 standard questions:

1. What is the date, month, and year?
2. What is the day of the week?
3. What is the name of this place?
4. What is your phone number?
5. How old are you?
6. When were you born?
7. Who is the current president?
8. Who was the president before him?
9. What was your mother’s maiden name?
10. Can you count backward from 20 by 3's?

The SPMSQ is evaluated based on the number of errors you make as follows: 0-2 errors (normal), 3-4 errors (mild impairment), 5 -7 errors (moderate impairment), and 8 or more errors (severe impairment).

For the assessment of mild neurocognitive impairment, some studies have shown that the ADAS-Coq is comparable to the MoCA in reliability.

However, researchers with the U.S. Preventive Services Task Force (USPSTF) argue that the SPMSQ has a lack of studies evidencing its effectiveness or that it is unclear how useful the evaluation is make clinical decision-making.

CAM Assessment

The Confusion Assessment Method (CAM) is an evaluation used to assess delirium. Delirium is similar to dementia, but it is not the same.

While dementia generally worsens slowly over months and years, delirium starts suddenly and can change dramatically over days or weeks (caused by things like a TBI, alcohol withdrawal, sleep deprivation, recreational drug overdose, and even a severe urinary tract infection). Delirium can develop independently but can sometimes occur alongside dementia.

The CAM is not a test taken by a patient but rather a technique used to detect the following symptoms based on an interview with a trained healthcare provider:

• Inattention (easy distraction and difficulty focusing during the interview)
• Disorganized thinking (including rambling or an illogical flow of thoughts)
• Altered levels of consciousness (such as being easily startled or difficult to arouse)
• Disorientation (the general state of confusion)
• Altered perceptions (such as hallucinations)
• Impaired memory
• Psychomotor agitation (such as tics, fidgeting, or restlessness)
• Psychomotor retardation (such as sluggishness or staring off into space)
• Abnormal sleep cycles

Delirium can be diagnosed based on the CAM test if the following criteria are met:

• Symptoms develop suddenly.
• Symptoms fluctuate, coming and going rather than remaining constant.
• Inattention, disorganized thinking, and altered levels of consciousness are all observed.

The other symptoms (such as impaired thinking and psychomotor retardation) may be useful in characterizing delirium and measuring the response to treatment.

The CAM assessment can help determine if the symptoms a person is experiencing are unrelated to Alzheimer's and are, in fact, treatable

Summary

The MoCA test is a simple, in-office test that can detect mild cognitive impairment and the early onset of dementia. It does so based on 11 questions that evaluate seven domains of cognitive function. The MoCA has a maximum score of 30, and anything below 26 is a sign of cognitive impairment.