Montreal Cognitive Assessment

The Montreal Cognitive Assessment (MoCA) was created in 1996 by Dr. Ziad 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:
 * 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.
 * 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 disease 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.

Other applications
Since the MoCA assesses multiple cognitive domains, it may be a useful cognitive screening tool for several neurological diseases 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 tumors (including high and low grade gliomas), 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.

Recommendation
The MoCA has been recommended by:

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).