The Montreal Cognitive Assessment (MoCA) is a brief cognitive screening test with high sensitivity and specificity for detecting Mild Neurocognitive Disorder / Mild Cognitive Impairment (MCI). The MoCA is particularly useful for detecting cognitive changes in those with higher levels of education, or where mild cognitive changes are the primary clinical concern.
The MoCA is best used for screening for mild neurocognitive disorder (i.e. - mild cognitive impairment). Cognitive tests are not diagnostic, and require interpretation by a clinician in conjunction with other factors, including a patient's clinical history, risk factors, and investigations.
All instructions in the MoCA may be repeated only once. The instructions and scoring below are described for MoCA version 7.1.
Instruct the patient: “Please draw a line going from a number to a letter in ascending order. Begin here [point to (1)] and draw a line from 1 then to A then to 2 and so on. End here [point to (E)].”
1
point is given if the patient successfully draws the following pattern: 1→A→2→B→3→C→4→D→5→E, without drawing any lines that crossPoint to the drawing, instructing: “Copy this drawing as accurately as you can.”
1
point is allocated for a correctly executed drawing. A point is not assigned if any of the below criteria are not met:Ensure that the subject does not look at his/her watch while performing the task and that no clocks are in sight. The examiner indicates the appropriate space and gives the following instructions: “Draw a clock. Put in all the numbers and set the time to 10 past 11.”
1
point is allocated for each of the following 3
criteria:Instruct the patient by beginning on the left, and point to each figure and say: “Tell me the name of this animal”.
1
point each is given for the following responses (for version 7.1):Read a list of 5 words at a rate of 1 word per second, giving the following instructions: “This is a memory test. I am going to read a list of words that you will have to remember now and later on. Listen carefully. When I am through, tell me as many words as you can remember. It doesn’t matter in what order you say them.” Mark a check in the allocated space for each word the subject produces on this first trial.
When the subject indicates that (s)he has finished (has recalled all words), or can recall no more words, read the list a second time with the following instructions: “I am going to read the same list for a second time. Try to remember and tell me as many words as you can, including words you said the first time.” Put a check in the allocated space for each word the subject recalls after the second trial. At the end of the second trial, inform the subject that (s)he will be asked to recall these words again by saying, “I will ask you to recall those words again at the end of the test.”
1
point for each sequence correctly repeated.Read the list of letters at a rate of one per second, after giving the following instructions: “I am going to read a sequence of letters. Every time I say the letter A, tap your hand once. If I say a different letter, do not tap your hand.”
1
point if there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A)
Give the following instructions: “Now, I will ask you to count by subtracting seven from 100, and then, keep subtracting seven from your answer until I tell you to stop.” Give this instruction twice if necessary.
3
points. Give no (0
) points for no correct subtractions, 1
point for one correction subtraction, 2
points for two-to-three correct subtractions, and 3
points if the participant successfully makes four or five correct subtractions. Count each correct subtraction of 7 beginning at 100. Each subtraction is evaluated independently; that is, if the participant responds with an incorrect number but continues to correctly subtract 7 from it, give a point for each correct subtraction. For example, a participant may respond “92 –> 85 –> 78 –> 71 –> 64” where the “92” is incorrect, but all subsequent numbers are subtracted correctly. This is only considered one error and the item would be given a score of 3.
Give the following instructions: “I am going to read you a sentence. Repeat it after me, exactly as I say it [pause]: I only know that John is the one to help today.” Following the response, say: “Now I am going to read you another sentence. Repeat it after me, exactly as I say it [pause]: The cat always hid under the couch when dogs were in the room.”
1
point for each sentence correctly repeated. Repetition must be exact. Be alert for errors that are omissions (e.g. - omitting “only”, “always”) and substitutions/additions (e.g. - “John is the one who helped today;” substituting “hides” for “hid”, altering plurals, etc.).
Give the following instructions: “Tell me as many words as you can think of that begin with a certain letter of the alphabet that I will tell you in a moment. You can say any kind of word you want, except for proper nouns (like Bob or Boston), numbers, or words that begin with the same sound but have a different suffix, for example, love, lover, loving. I will tell you to stop after one minute. Are you ready? [Pause] Now, tell me as many words as you can think of that begin with the letter F. [time for 60 sec]. Stop.”
1
point if the subject generates 11 words or more in 60 seconds. Record the subject’s response in the bottom or side margins.
Ask the patient to explain what each pair of words has in common, starting with the example: “Tell me how an orange and a banana are alike”. If the subject answers in a concrete manner, then say only one additional time: “Tell me another way in which those items are alike”. If the subject does not give the appropriate response (fruit), say, “Yes, and they are also both fruit.” Do not give any additional instructions or clarification. After the practice trial, say: “Now, tell me how a train and a bicycle are alike”. Following the response, administer the second trial, saying: “Now tell me how a ruler and a watch are alike”. Do not give any additional instructions or prompts.
1
point to each item pair correctly answered. The following responses are acceptable:Give the following instructions: “I read some words to you earlier, which I asked you to remember. Tell me as many of those words as you can remember.“ Make a check mark for each of the words correctly recalled spontaneously without any cues, in the allocated space.
1
point for each word recalled freely without any cues.
Allocate 1
point for each word recalled freely without any cues.
1
point for each item correctly answered. The patient must tell the exact date and the exact place (name of hospital, clinic, office). No points are allocated if the patient makes an error of one day for the day and date.
Sum all subscores listed on the right-hand side. Add 1
point for an individual who has 12 years or fewer of formal education, for a possible maximum of 30 points. A final total score of 26
and above is considered normal.
Category | Test | Cognitive domain | Neuroanatomical region |
---|---|---|---|
Visuospatial/Executive | Trails | Executive function | • Dorsolateral prefrontal cortex (DLFPC) • Trail making requires cognitive flexibility generated through the dorsolateral and medial prefrontal cortices.[3] |
Visuospatial/Executive | Cube | • Executive function • Visual/spatial perception, construction praxis | • Dorsolateral prefrontal cortex • Right parietal lobe |
Visuospatial/Executive | Clock drawing | • Constructional praxis • Executive function | • Right parietal lobe • Dorsolateral prefrontal cortex |
Naming | Animals | • Semantic knowledge • Vocalization and articulation | • Anterior temporal lobes (bilateral) • Broca’s area and insular cortex |
Memory | 5 word repeat | Working memory | Anterior temporal lobes (bilateral) |
Attention | Digit list | Attention/vigilance | Dorsolateral prefrontal cortex |
Attention | Tapping | Response inhibition | Orbitofrontal cortex |
Attention | Serial 7s | Working memory, attention, calculation | Dorsolateral prefrontal cortex, left parietal lobe |
Language | Sentence repeat | • Working memory/executive function • Aphasia | Dorsolateral prefrontal cortex |
Language | Fluency (F-words in 1 minute) | • Working memory/executive function • Phonemic fluency | Dorsolateral prefrontal cortex |
Abstraction | Similarities | Conceptualization, abstract thinking, higher level thinking | Dorsolateral prefrontal cortex |
Delayed Recall | 5 word delayed recall | Memory | Hippocampus |
Orientation | Date, time, place | Memory | Hippocampus |
Suggested cut-off scores by the creator of the MoCA, are as follows:[4]
Normal Controls | Mild Cognitive Impairment | Alzheimer's Disease | |
---|---|---|---|
N | 90 | 94 | 93 |
Average score | 27.4 | 22.1 | 16.2 |
Standard deviation | 2.2 | 3.1 | 2.8 |
Range | 25.2 | 19.0-25.2 | 11.4-21.0 |
Suggested cut-off score | ≥ 26 | < 26 | < 26 |
Newer normative (age and education) MMSE and MoCA datasets from The Irish Longitudinal Study on Ageing (TILDA), based on a geriatric population, was also recently published in 2013.[5] |
The Montreal Cognitive Assessment – Basic (MoCA-B) is used for screening of mild cognitive impairment in illiterate and low education individuals. The MoCA-B cognitive domains similar to the original MoCA (executive functions, language, orientation, calculations, conceptual thinking, memory, visuoperception, attention and concentration).
The MoCA can also be performed remotely over the telephone or via a videoconferencing.[6] The MoCA version with no visual elements (i.e. - MoCA Blind version) is scored out of 22, with a cut-off score ≥ 19.
The MoCA can also be done via video assessment.[7] The principles of cognitive testing with the MoCA remains the same with some minor changes: