Montreal Cognitive Assessment (MoCA)

The Montreal Cognitive Assessment (MoCA) is a standardized neuropsychological screening tool developed to evaluate cognitive function and detect mild cognitive impairment (MCI) or early signs of dementia. The test was created by Nasreddine et al. in 2005 as a more sensitive alternative to the Mini-Mental State Examination (MMSE) for identifying cognitive deficits in individuals with mild neurocognitive disorder【1】.

Purpose and Applications

MoCA was developed to:

• Identify mild cognitive impairment (MCI) and early dementia

• Evaluate cognitive function in patients with neurological disorders such as Parkinson’s disease, stroke, Alzheimer’s disease, multiple sclerosis, Huntington’s disease, and others【2】

• Assess cognition in patients with cardiovascular disease, chronic kidney disease, substance abuse, and other medical conditions that may affect the brain【3】

MoCA is widely used in both primary and specialist healthcare as a quick and reliable method to detect cognitive impairments.

Test Structure and Content

MoCA covers multiple cognitive domains to provide a comprehensive assessment of cognitive function. It consists of 11 categories:

1. Visuospatial and Executive Function

   • Trail-making (alternating numbers and letters)

   • Copying a cube

   • Max points: 2

2. Clock Drawing

   • Draw a clock with correct contour, numbers, and hands (11:10)

   • Max points: 3

3. Animal Naming

   • Identify a lion, rhinoceros, and camel

   • Max points: 3

4. Attention

   • Repeat digits forward and backward

   • Letter A recognition in a sequence

   • Max points: 3

5. Serial 7 Subtractions

   • Subtract 7 from 100 five times (100 → 93 → 86 → 79 → 72 → 65)

   • Max points: 3

6. Sentence Repetition

   • Repeat two sentences verbatim:

     • “I only know that John is the one to help today.”

     • “The cat always hid under the sofa when dogs were in the room.”

   • Max points: 2

7. Verbal Fluency

   • Generate as many words as possible beginning with the letter F in one minute

   • Max points: 1

8. Abstraction

   • Explain similarity between train and bicycle (means of transport)

   • Explain similarity between clock and ruler (measuring instruments)

   • Max points: 2

9. Delayed Recall (Memory)

   • Recall 5 words without cues: face, velvet, church, daisy, red

   • Max points: 5

10. Orientation

11. State correct day, date, month, year, place, and city

12. Max points: 6

Scoring and Interpretation

• Total score: 0–30 (higher = better cognitive function)

• ≥26 points: Normal cognitive function【4】

• 22–25 points: Mild cognitive impairment (MCI)【5】

• 18–21 points: Moderate cognitive impairment – further assessment recommended【6】

• <18 points: Severe cognitive impairment, often consistent with dementia【7】

• Adjustment: If the patient has ≤12 years of education, add 1 point to the total score【8】

Clinical Significance

• Sensitivity: 90%

• Specificity: 87% at cut-off 26【9】

• MoCA is more sensitive than MMSE for detecting early cognitive decline.

• Predictive of cognitive deterioration in Parkinson’s disease, Alzheimer’s disease, and cerebrovascular conditions【10】.

Limitations

• Low specificity at cut-off 26 (31%), which may result in false positives【11】

• Requires training and certification for correct administration【12】

• Language and cultural differences can affect results – localized versions are available【13】

Conclusion

The Montreal Cognitive Assessment (MoCA) is a highly sensitive and effective screening tool for detecting mild cognitive impairment and early dementia. It is simple to administer, requires only 10–15 minutes, and evaluates multiple cognitive domains. MoCA is especially valuable in both clinical practice and research, though it should be used alongside other clinical evaluations for the most accurate diagnostic outcomes

Refrences

1. Bezdicek, O., Majerova, V., Novak, M., Nikolai, T., Ruzicka, E., & Roth, J. (2013). Validity of the Montreal Cognitive Assessment in the detection of cognitive dysfunction in Huntington’s Disease. Applied Neuropsychology: Adult, 20, 33-40. DOI: 10.1080/09084282.2012.670158

2. Bruijnen, C. J. W. H., Jansen, M., Dijkstra, B. A. G., Walvoort, S. J. W., Lugtmeijer, S., Markus, W., Jong, C. A. J. D., & Kessels, R. P. C. (2019). The Montreal Cognitive Assessment (MoCA) as a cognitive screen in addiction health care: A validation study for clinical practice. Journal of Substance Use, 24(1), 47–54. https://doi.org/10.1080/14659891.2018.1497102

3. Carson, N., Leach, L., & Murphy, K. J. (2017). A re-examination of Montreal Cognitive Assessment (MoCA) cutoff scores. International Journal of Geriatric Psychiatry, 33(2), 379–388. doi: 10.1002/gps.4756

4. Chou, K. L., Amick, M. M., et al. (2010). "A recommended scale for cognitive screening in clinical trials of Parkinson's disease." Movement Disorders 25(15): 2501-2507.

5. Cumming, T. B., Lowe, D., Linden, T., & Bernhardt, J. (2018). The AVERT MoCA Data: Scoring Reliability in a Large Multicenter Trial. Assessment, 1073191118771516. https://doi.org/10.1177/1073191118771516

6. Dalrymple-Alford, J., MacAskill, M., et al. (2010). "The MoCA Well-suited screen for cognitive impairment in Parkinson disease." Neurology 75(19): 1717-1725.

7. Ewert, V., Pelletier, S., Alarcon, R., Nalpas, B., Donnadieu-Rigole, H., Trouillet, R., & Perney, P. (2017). Determination of MoCA Cutoff Score in Patients with Alcohol Use Disorders. Alcoholism: Clinical and Experimental Research, 42(2), 403–412. doi: 10.1111/acer.13547

8. Fazeli, P. L., Casaletto, K. B., Paolillo, E., Moore, R. C., Moore, D. J., & the HNRP Group. (2017). Screening for neurocognitive impairment in HIV-positive adults aged 50 years and older: Montreal Cognitive Assessment relates to self-reported and clinician-rated everyday functioning. Journal of Clinical & Experimental Neuropsychology, 39(9), 842–853. https://doi.org/10.1080/13803395.2016.1273319

9. Feeney, J., Savva, G. M., O’Regan, C., King-Kallimanis, B., Cronin, H., & Kenny, R. A. (2016). Measurement error, reliability, and minimum detectable change in the Mini-Mental State Examination, Montreal Cognitive Assessment, and Color Trails Test among community living middle-aged and older adults. Journal of Alzheimer's Disease, 53(3), 1107-1114.

10. Gill, D. J., Freshman, A., et al. (2008). "The Montreal cognitive assessment as a screening tool for cognitive impairment in Parkinson's disease." Mov Disord 23(7): 1043-1046.

11. Goldstein, F. C., Ashley, A. V., Miller, E., Alexeeva, O., Zanders, L., & King, V. (2014). Validity of the Montreal Cognitive Assessment as a Screen for Mild Cognitive Impairment and Dementia in African Americans. Journal of Geriatric Psychiatry and Neurology, 27(3), 199–203. https://doi.org/10.1177/0891988714524630

12. Hoops, S., Nazem, S., et al. (2009). "Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease." Neurology 73(21): 1738-1745.

13. Kletzel, S. L., Hernandez, J. M., Miskiel, E. F., Mallinson, T., & Pape, T. L.-B. (2017). “Evaluating the performance of the Montreal Cognitive Assessment in early stage Parkinson's disease”. Parkinsonism & Related Disorders, 37, 58–64. doi:10.1016/j.parkreldis.2017.01.012

14. Koski, L. (2013). Validity and applications of the Montreal Cognitive Assessment for the assessment of vascular cognitive impairment. Cerebrovascular Disease, 36, 6-13. DOI: 10.1159/000352051

15. Lam, B., Middleton, L. E., Masellis, M., Stuss, D. T., Harry, R. D., Kiss, A., & Black, S. E. (2013). Criterion and Convergent Validity of the Montreal Cognitive Assessment with Screening and Standardized Neuropsychological Testing. Journal of the American Geriatrics Society, 61(12), 2181–2185. https://doi.org/10.1111/jgs.12541

16. Malek-Ahmadi, M., Powell, J. J., Belden, C. M., O’Connor, K., Evans, L., Coon, D. W., & Nieri, W. (2015). Age- and education-adjusted normative data for the Montreal Cognitive Assessment (MoCA) in older adults age 70–99. Aging, Neuropsychology, and Cognition, 22(6), 755–761. https://doi.org/10.1080/13825585.2015.1041449

17. McLennan, S. N., Mathias, J. L., Brennan, L. C., & Stewart, S. (2011). Validity of the Montreal Assessment (MoCA) as a screening test for Mild Cognitive Impairment (MCI) in a cardiovascular population. Journal of Geriatric Psychiatry and Neurology, 24(1), 33-38. DOI: 10.1177/0891988710390813

18. MoCA Montreal Cognitive Assessment (2019). FAQ. Retrieved from https://www.mocatest.org/

19. Nasreddine, Z. S., Phillips, N. A., et al. (2005). "The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment." Journal of the American Geriatrics Society 53(4): 695-699.

20. Nazem, S., Siderowf, A. D., et al. (2009). "Montreal Cognitive Assessment Performance in Patients with Parkinson's Disease with “Normal” Global Cognition According to Mini‐Mental State Examination Score." Journal of the American Geriatrics Society 57(2): 304-308.

21. Roalf, D. R., Moberg, P. J., Xie, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two common screening instruments for the classification of Alzheimer’s disease, mild cognitive impairment and healthy aging. Alzheimer’s & Dementia : The Journal of the Alzheimer’s Association, 9(5), 529–537. https://doi.org/10.1016/j.jalz.2012.10.001

22. Robben, S. H., Sleegers, M. J., et al. (2010). "Pilot study of a three‐step diagnostic pathway for young and old patients with Parkinson's disease dementia: screen, test and then diagnose." International journal of geriatric psychiatry 25(3): 258-265.

23. Rossetti, H. C., Lacritz, L. H., et al. (2011). "Normative data for the Montreal Cognitive Assessment (MoCA) in a population-based sample." Neurology 77(13): 1272-1275.

24. Smith, T., Gildeh, N., et al. (2007). "The Montreal Cognitive Assessment: validity and utility in a memory clinic setting." Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 52(5): 329-332.

25. Tiffin-Richards, F. E., Costa, A. S., Holschbach, B., Frank, R. D., Vassiliadou, A., Krüger, T., Kuckuck, K., Gross, T., Eitner, F., Floege, J., Schulz, J. B., & Reetz, K. (2014). The Montreal Cognitive Assessment (MoCA)—a sensitive screening instrument for detecting cognitive impairment in chronic hemodialysis patients. PLOS ONE, 9(10), 1-9. https://doi.org/10.1371/journal.pone.0106700

26. Toglia, J., Fitzgerald, K. A., et al. (2011). "The Mini-Mental State Examination and Montreal Cognitive Assessment in persons with mild subacute stroke: relationship to functional outcome." Archives of Physical Medicine and Rehabilitation 92(5): 792-798.

27. Yang, Z., Abdul Rashid, N.A., Feng Quek, Y., Lam, M., Mei See, Y., Maniam, Y., Dauwels, J., Leet Tan, B., & Lee, J. (2018). “Montreal cognitive assessment as a screening instrument for cognitive impairments in schizophrenia.” Schizophrenia Research, 199. https://doi.org/10.1016/j.schres.2018.03.008

28. Zadikoff, C., Fox, S. H., et al. (2008). "A comparison of the mini mental state exam to the Montreal cognitive assessment in identifying cognitive deficits in Parkinson's disease." Mov Disord 23(2): 297-299.