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The Montreal Cognitive Assessment (MoCA) is a widely used screening assessment for detecting cognitive impairment. It was created in 1996 by Ziad Nasreddine in
Montreal Montreal is the List of towns in Quebec, largest city in the Provinces and territories of Canada, province of Quebec, the List of the largest municipalities in Canada by population, second-largest in Canada, and the List of North American cit ...
,
Quebec Quebec is Canada's List of Canadian provinces and territories by area, largest province by area. Located in Central Canada, the province shares borders with the provinces of Ontario to the west, Newfoundland and Labrador to the northeast, ...
. It was validated in the setting of mild cognitive impairment (MCI), and has subsequently been adopted in numerous other clinical settings. This test consists of 30 points and takes 10 minutes for the individual to complete. The original English version is performed in seven steps, which may change in some countries dependent on education and culture. The basics of this test include
short-term memory Short-term memory (or "primary" or "active memory") is the capacity for holding a small amount of information in an active, readily available state for a short interval. For example, short-term memory holds a phone number that has just been recit ...
,
executive function In cognitive science and neuropsychology, executive functions (collectively referred to as executive function and cognitive control) are a set of cognitive processes that support goal-directed behavior, by regulating thoughts and actions thro ...
, attention, focus, and more.


Format

The MoCA is a one-page 30-point test administered in approximately 10 minutes. The test and administration instructions are available for clinicians online. The test is available in 46 languages and
dialect A dialect is a Variety (linguistics), variety of language spoken by a particular group of people. This may include dominant and standard language, standardized varieties as well as Vernacular language, vernacular, unwritten, or non-standardize ...
s (as of 2017). 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 five minutes. * Visuospatial abilities are assessed using a clock drawing task (3 points) and a three-dimensional cube copy (1 point). * Multiple aspects of
executive function In cognitive science and neuropsychology, executive functions (collectively referred to as executive function and cognitive control) are a set of cognitive processes that support goal-directed behavior, by regulating thoughts and actions thro ...
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 Working memory is a cognitive system with a limited capacity that can Memory, hold information temporarily. It is important for reasoning and the guidance of decision-making and behavior. Working memory is often used synonymously with short-term m ...
are evaluated using a sustained attention task (target detection using tapping; 1 point), serial sevens (serial subtraction task; 3 points), and digit span forward and backward (1 point each). * Language is assessed using a three-item confrontation naming task with low-familiarity animals (
lion The lion (''Panthera leo'') is a large Felidae, cat of the genus ''Panthera'', native to Sub-Saharan Africa and India. It has a muscular, broad-chested body (biology), body; a short, rounded head; round ears; and a dark, hairy tuft at the ...
,
camel A camel (from and () from Ancient Semitic: ''gāmāl'') is an even-toed ungulate in the genus ''Camelus'' that bears distinctive fatty deposits known as "humps" on its back. Camels have long been domesticated and, as livestock, they provid ...
,
rhinoceros A rhinoceros ( ; ; ; : rhinoceros or rhinoceroses), commonly abbreviated to rhino, is a member of any of the five extant taxon, extant species (or numerous extinct species) of odd-toed ungulates (perissodactyls) in the family (biology), famil ...
; 3 points), repetition of two syntactically complex sentences (2 points), and the aforementioned fluency task. * Abstract reasoning is assessed using a describe-the-similarity task with 2 points being available. * Finally, orientation to time and place is evaluated by asking the subject for the date and the city in which the test is occurring (6 points). Because MoCA is English-specific, linguistic and cultural translations are made in order to adapt the test in other countries. Multiple cultural and linguistic variables may affect the norms of the MoCA across different countries and languages, e.g. Swedish. Several cut-off scores have been suggested across different languages to compensate for the
education Education is the transmission of knowledge and skills and the development of character traits. Formal education occurs within a structured institutional framework, such as public schools, following a curriculum. Non-formal education als ...
level of the population, and several modifications were also necessary to accommodate certain linguistic and cultural differences across different languages or countries; however, not all versions have been validated.


Efficacy


MoCA test study

A MoCA test validation study by Nasreddine in 2005 showed that the MoCA was a promising tool for detecting MCI and early
Alzheimer's disease Alzheimer's disease (AD) is a neurodegenerative disease and the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in remembering recent events. As the disease advances, symptoms can include problems wit ...
compared with the well-known Mini-Mental State Examination (MMSE). According to the validation study, the
sensitivity and specificity In medicine and statistics, sensitivity and specificity mathematically describe the accuracy of a test that reports the presence or absence of a medical condition. If individuals who have the condition are considered "positive" and those who do ...
of the MoCA for detecting MCI were 90% and 87% respectively, compared with 18% and 100% respectively for the MMSE. Subsequent studies in other settings were less promising, though generally superior to the MMSE. Other studies have tested the MoCA on patients with Alzheimer's disease. People with
hearing loss Hearing loss is a partial or total inability to hear. Hearing loss may be present at birth or acquired at any time afterwards. Hearing loss may occur in one or both ears. In children, hearing problems can affect the ability to acquire spo ...
, which commonly occurs alongside
dementia Dementia is a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform activities of daily living, everyday activities. This typically invo ...
, score worse in the MoCA test, which could lead to a false diagnosis of dementia. Researchers have developed an adapted version of the MoCA test, which is accurate and reliable and avoids the need for people to listen and respond to questions.


Recommendations

The
National Institutes of Health The National Institutes of Health (NIH) is the primary agency of the United States government responsible for biomedical and public health research. It was founded in 1887 and is part of the United States Department of Health and Human Service ...
and the Canadian Stroke Network recommended selected subsets of the MoCA for the detection of vascular cognitive impairment.


Scoring

MoCA scores range between 0 and 30. A score of 26 or over is considered to be normal. In a study, people without cognitive impairment scored an average of 27.4; people with MCI scored an average of 22.1; people with
Alzheimer's disease Alzheimer's disease (AD) is a neurodegenerative disease and the cause of 60–70% of cases of dementia. The most common early symptom is difficulty in remembering recent events. As the disease advances, symptoms can include problems wit ...
scored an average of 16.2. In a study by Ihle-Hansen et al. (2017), of 3,413 Norwegian participants aged 63–65, of whom 47% had higher education (over 12 years), under 5% of subjects scored 30/30 with a mean MoCA score of 25.3 and 49% scoring below the suggested cut-off of 26 points, leading the authors to suggest that "the cut-off score may have been set too high to distinguish normal cognitive function from MCI".


Normalization studies

In addition to a growing amount of international normative data, the Memory Index Score (MIS), which is included in the most recent test versions, is gaining increasing diagnostic importance. In a Dutch regression-based normative data study, normative values have been published for both the total value of the MoCA and for the included Memory Index Score for a total of seven age cohorts between 18 and 91 years.


Other applications

Since the MoCA assesses multiple cognitive domains, it can be a useful cognitive screening tool for several neurological diseases that affect younger populations, such as
Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a neurodegenerative disease primarily of the central nervous system, affecting both motor system, motor and non-motor systems. Symptoms typically develop gradually and non-motor issues become ...
, vascular cognitive impairment,
Huntington's disease Huntington's disease (HD), also known as Huntington's chorea, is an incurable neurodegenerative disease that is mostly Genetic disorder#Autosomal dominant, inherited. It typically presents as a triad of progressive psychiatric, cognitive, and ...
,
brain metastasis A brain metastasis is a cancer that has metastasis, metastasized (spread) to the brain from another location in the body and is therefore considered a brain tumor, secondary brain tumor. The metastasis typically shares a Cancer cell, cancer cell ...
, sleep behaviour disorder, primary
brain tumor A brain tumor (sometimes referred to as brain cancer) occurs when a group of cells within the Human brain, brain turn cancerous and grow out of control, creating a mass. There are two main types of tumors: malignant (cancerous) tumors and benign ...
s (including high- and low-grade
glioma A glioma is a type of primary tumor that starts in the glial cells of the brain or spinal cord. They are malignant but some are extremely slow to develop. Gliomas comprise about 30% of all brain and central nervous system tumors and 80% of ...
s),
multiple sclerosis Multiple sclerosis (MS) is an autoimmune disease resulting in damage to myelinthe insulating covers of nerve cellsin the brain and spinal cord. As a demyelinating disease, MS disrupts the nervous system's ability to Action potential, transmit ...
and other conditions such as
traumatic brain injury A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity ranging from mild traumatic brain injury (mTBI/concussion) to severe traumati ...
, cognitive impairment from
schizophrenia Schizophrenia () is a mental disorder characterized variously by hallucinations (typically, Auditory hallucination#Schizophrenia, hearing voices), delusions, thought disorder, disorganized thinking and behavior, and Reduced affect display, f ...
and
heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome caused by an impairment in the heart's ability to Cardiac cycle, fill with and pump blood. Although symptoms vary based on which side of the heart is affected, HF ...
. The test is also used in hospitals to determine whether patients should be allowed to live alone or with a home aide.


In American politics

Nikki Haley campaigned for the Republican presidential nomination partially on a platform plank that would have required all politicians aged 75 or older take the MoCA. This proposal would have required both incumbent President
Joe Biden Joseph Robinette Biden Jr. (born November 20, 1942) is an American politician who was the 46th president of the United States from 2021 to 2025. A member of the Democratic Party (United States), Democratic Party, he served as the 47th vice p ...
and former President
Donald Trump Donald John Trump (born June 14, 1946) is an American politician, media personality, and businessman who is the 47th president of the United States. A member of the Republican Party (United States), Republican Party, he served as the 45 ...
, but not Haley, take the MoCA. Trump was given the MoCA in 2018 by then–White House physician Ronny Jackson. Trump's repeated use of the phrase " Person, woman, man, camera, TV" while describing the test became an
Internet meme An Internet meme, or meme (, Help:Pronunciation respelling key, ''MEEM''), is a cultural item (such as an idea, behavior, or style) that spreads across the Internet, primarily through Social media, social media platforms. Internet memes manif ...
and went viral on social media platforms. According to ''
The Washington Post ''The Washington Post'', locally known as ''The'' ''Post'' and, informally, ''WaPo'' or ''WP'', is an American daily newspaper published in Washington, D.C., the national capital. It is the most widely circulated newspaper in the Washington m ...
'', Trump has frequently distorted or misrepresented the nature of the test. Amid concerns about his age and health, Biden declined to undergo a cognitive exam, stating that he has "a cognitive test every single day" in performing his presidential duties.


See also

*
Mini–mental state examination The mini–mental state examination (MMSE) or Folstein test is a 30-point questionnaire that is used extensively in clinical and research settings to measure cognitive impairment. It is commonly used in medicine and allied health to screen for d ...


References


External links


Montreal Cognitive Assessment (MoCA)
(
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) Version 8.1 English {{Neuropsychology tests Cognitive impairment and dementia screening and assessment tools Cognitive tests Neuropsychological tests Geriatrics 1996 introductions