Montreal Cognitive Assessment (MoCA)

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)].”

Scoring

  • 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 cross
  • Any error that is not immediately self-corrected (meaning corrected before moving on to the Cube task) earns a score of 0. A point is not given if the patient draws a line to connect the end (E) to the beginning (1)

Point to the drawing, instructing: “Copy this drawing as accurately as you can.”

Scoring

1 point is allocated for a correctly executed drawing. A point is not assigned if any of the below criteria are not met:
  • Drawing must be three-dimensional
  • All lines are drawn
  • All lines meet with little or no space
  • No line is added
  • Lines are relatively parallel and their length is similar (rectangular prisms are accepted)
  • For the cube drawing, the cube’s orientation in space must be preserved

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.”

Scoring

1 point is allocated for each of the following 3 criteria:
  • Contour (1 point): the clock contour must be drawn (either a circle or a square). Only minor distortions are acceptable (e.g. - slight imperfection on closing the circle). If the numbers are arranged in a circular manner but the contour is not drawn the contour is scored as incorrect
  • Numbers (1 point): all clock numbers must be present with no additional numbers. Numbers must be in the correct order, upright and placed in the approximate quadrants on the clock face. Roman numerals are acceptable. The numbers must be arranged in a circular manner (even if the contour is a square). All numbers must either be placed inside or outside the clock contour. If the subject places some numbers inside the clock contour and some outside the clock contour, (s)he does not receive a point for Numbers.
  • Hands (1 point): there must be two hands jointly indicating the correct time. The hour hand must be clearly shorter than the minute hand. Hands must be centered within the clock face with their junction close to the clock center.

Instruct the patient by beginning on the left, and point to each figure and say: “Tell me the name of this animal”.

Scoring

1 point each is given for the following responses (for version 7.1):
  1. Camel or dromedary
  2. Lion
  3. Rhinoceros or rhino

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.”

Scoring

There is no scoring in this section.
  • Forward Digit Span: Give the following instructions: “I am going to say some numbers and when I am through, repeat them to me exactly as I said them.“ Read the five number sequence at a rate of one digit per second.
  • Backward Digit Span: Give the following instructions: ”Now I am going to say some more numbers, but when I am through you must repeat them to me in the backwards order.“ Read the three number sequence at a rate of one digit per second.

Scoring

Allocate 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.”

Scoring

Give 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.

Scoring

This item is scored out of 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.

Scoring

Scoring: Allocate 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.”

Scoring

Allocate 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.

Scoring

Only the last two item pairs are scored. Give 1 point to each item pair correctly answered. The following responses are acceptable:
  • Train-bicycle = means of transportation / means of travelling / you take trips in both ( = they have wheels, is not acceptable)
  • Ruler-watch = measuring instruments / used to measure ( = they have numbers, is not 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.

Optional Step

Following the delayed free recall trial, prompt the subject with the semantic category cue provided below for any word not recalled. Make a check mark in the allocated space if the subject remembered the word with the help of a category or multiple-choice cue. Prompt all non-recalled words in this manner. If the subject does not recall the word after the category cue, give him/her a multiple choice trial, using the following example instruction, “Which of the following words do you think it was, NOSE, FACE, or HAND?” Use the following category and/or multiple-choice cues for each word, when appropriate:
  • FACE: category cue: part of the body multiple choice: nose, face, hand
  • VELVET: category cue: type of fabric multiple choice: denim, cotton, velvet
  • CHURCH: category cue: type of building multiple choice: church, school, hospital
  • DAISY: category cue: type of flower multiple choice: rose, daisy, tulip
  • RED: category cue: a colour multiple choice: red, blue, green

Scoring

  • Allocate 1 point for each word recalled freely without any cues.
  • No points are allocated for words recalled with a cue. A cue is used for clinical information purposes only and can give the test interpreter additional information about the type of memory disorder. For memory deficits due to retrieval failures, performance can be improved with a cue. For memory deficits due to encoding failures, performance does not improve with a cue.

Clinical Correlation Required

If the patient can recall words with multiple choice or category cues, then it suggests the words were encoded in the hippocampus, but unable to be retrieved. This would suggest a frontal lobe deficit, more commonly seen in vascular dementia or Parkinson’s dementia.[1]

Allocate 1 point for each word recalled freely without any cues.

  • Give the following instructions: ”Tell me the date today“. If the subject does not give a complete answer, then prompt accordingly by saying: ”Tell me the [year, month, exact date, and day of the week].“ Then say: ”Now, tell me the name of this place, and which city it is in.“

Scoring

  • Give 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.

MoCA Cognitive Domains and Neuroanatomy

Category Test Cognitive domain Neuroanatomical region
Visuospatial/Executive Trails Executive function Dorsolateral prefrontal cortex (DLFPC)
Visuospatial/Executive Cube • Executive function
• Visual/spatial perception, construction praxis
• Dorsolateral prefrontal cortex
• Right parietal lobe
Visuospatial/Executive Clock • 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 Dorsolateral prefrontal cortex
Language Fluency (F-words in 1 minute) • Working memory/executive function
• Phonemic fluency
Dorsolateral prefrontal cortex
Abstraction Similarities Abstraction 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:[2]

MoCA Cut-off Scores

Nasreddine, Ziad S., et al. MoCA: a brief screening tool for mild cognitive impairment. J Am Geri 53.4 (2005): 695-699.
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

Other Data Sets

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.[3] Download

The MoCA can also be performed remotely over the telephone or via a videoconferencing.[4] 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.[5] The principles of cognitive testing with the MoCA remains the same with some minor changes:

  • Trails: Show the trail and say: “Please tell me where the arrow should go next to follow the pattern I am showing you”
  • Cube: Show the cube and say: “Copy the cube”
  • Date: “Look directly at the camera and tell me today's date, day of the week, month and year”
  • Place: “What hospital/clinic/institution am I calling you from?”
  • City: “What is the city in which our hospital/clinic/institution is located?”