Profiles of cognitive subtest impairment in the Montreal Cognitive Assessment (MoCA) in a research cohort with normal Mini-Mental State Examination (MMSE) scores

Among screening tools for cognitive impairment in large cohorts, the Montreal Cognitive Assessment (MoCA) seems to be more sensitive to early cognitive impairment than the Mini-Mental State Examination (MMSE), particularly after transient ischemic attack or minor stroke. We reasoned that if MoCA-detected early cognitive impairment is pathologically significant, then it should be specifically associated with the presence of white matter hyperintensities (WMHs) and reduced fractional anisotropy (FA) on magnetic resonance imaging. Consecutive eligible patients with transient ischemic attack or minor stroke (Oxford Vascular Study) underwent magnetic resonance imaging and cognitive assessment. We correlated MoCA and MMSE scores with WMH and FA, then specifically studied patients with low MoCA and normal MMSE. Among 400 patients, MoCA and MMSE scores were significantly correlated (all P<0.001) with WMH volumes (rMoCA=-0.336; rMMSE=-0.297) and FA (rMoCA=0.409; rMMSE=0.369) and-on voxel-wise analyses-with WMH in frontal white matter and reduced FA in almost all white matter tracts. However, only the MoCA was independently correlated with WMH volumes (r=-0.183; P<0.001), average FA values (r=0.218; P<0.001), and voxel-wise reduced FA in anterior tracts after controlling for the MMSE. In addition, patients with low MoCA but normal MMSE (n=57) had higher WMH volumes (t=3.1; P=0.002), lower average FA (t=-4.0; P<0.001), and lower voxel-wise FA in almost all white matter tracts than those with normal MoCA and MMSE (n=238). In patients with transient ischemic attack or minor stroke, early cognitive impairment detected with the MoCA but not with the MMSE was independently associated with white matter damage on magnetic resonance imaging, particularly reduced FA.

Objective To evaluate the Montreal cognitive assessment (MoCA) for detecting the mild cognitive impairment (MCI) in brain trauma patients with normal mini-mental state examination (MMSE) scores. Methods Fifty brain trauma patients with normal MMSE scores hospitalized from January 2013 to June 2014 were subjected to the MoCA test. The patients were classified as cognitive impairment group scored less than 26 on the MoCA and cognitive normal group scored 26 or above on the MoCA. Differences in MMSE and MoCA scores of the two groups were compared. Receiver operative characteristic (ROC) curve was used to determine the optimal cut-off scores in screening for MCI. Results Overall MMSE and MoCA scores were (27.84±0.89)points and (23.24±2.90)points. There was a positive correlation between MoCA and MMSE total scores (r=0.355 2, P<0.05). MCI was found in 79% of the brain trauma patients using the MoCA. MMSE total score and subscores were all similar between the two groups. MoCA total score and subscores of attention, language, abstraction and delayed recall were much higher in cognitive normal group than in cognitive impairment group (P<0.05), but there were no significant differences in visuospatial, naming and oritention domains. Area under the ROC curve for MoCA(0.871±0.038) was larger compared with MMSE (0.796±0.054) (Z=3.592, P<0.05). The optimal cut-off scores of MoCA and MMSE for the identification of MCI were 25.5 and 28.5 respectively. Conclusions MoCA and MMSE total scores are positively correlated. MoCA is a better detector for the identification of MCI in brain trauma patients than the MMSE. Key words: Craniocerebral trauma; Cognition disorders; Montreal cognitive assessment/mini-mental state examination

Detection of cognitive impairment in patients with brain metastases is important for both patient management and clinical trials. The most commonly used cognitive screen, the Mini Mental State Examination (MMSE), though convenient, is not sensitive in these patients. More sensitive tools are less convenient and, therefore, uncommonly used. Therefore, a practical and sensitive tool is needed. The Montreal Cognitive Assessment (MoCA) is a good candidate, shown to be sensitive in detecting mild cognitive impairment in the pre-dementia setting. This study is the first to explore the MoCA in cancer patients and is aimed at determining the feasibility of administering the MoCA in brain tumor patients. The secondary objective is to explore the relationship between MoCA and MMSE scores. Forty patients with brain metastases being treated with whole brain radiotherapy were prospectively accrued from January to May 2007. All patients were administered both the MoCA and MMSE. The MoCA was completed in 10 min in 88% of patients. 92% of all the patients found the MoCA to be only mildly or not at all inconvenient. Eighty percent of the patients were deemed cognitively impaired by the MoCA compared with 30% by the MMSE (p < 0.0001). Of the 28 patients with a normal MMSE, 71% had cognitive impairment according to the MoCA. Overall, 50% of the patients had an abnormal MoCA, yet normal MMSE. The MoCA was well tolerated and provided additional information over the MMSE, justifying further validation studies of the MoCA in brain tumor patients.

Background: The Montreal Cognitive Assessment (MoCA) appears more sensitive to mild cognitive impairment (MCI) than the Mini-Mental State Examination (MMSE): over 50% of TIA and stroke patients with an MMSE score of ≥27 (‘normal’ cognitive function) at ≥6 months after index event, score <26 on the MoCA, a cutoff which has good sensitivity and specificity for MCI in this population. We hypothesized that sensitivity of the MoCA to MCI might in part be due to detection of different patterns of cognitive domain impairment. We therefore compared performance on the MMSE and MoCA in subjects without major cognitive impairment (MMSE score of ≥24) with differing clinical characteristics: a TIA and stroke cohort in which frontal/executive deficits were expected to be prevalent and a memory research cohort. Methods: The MMSE and MoCA were done on consecutive patients with TIA or stroke in a population-based study (Oxford Vascular Study) 6 months or more after the index event and on consecutive subjects enrolled in a memory research cohort (the Oxford Project to Investigate Memory and Ageing). Patients with moderate-to-severe cognitive impairment (MMSE score of <24), dysphasia or inability to use the dominant arm were excluded. Results: Of 207 stroke patients (mean age ± SD: 72 ± 11.5 years, 54% male), 156 TIA patients (mean age 71 ± 12.1 years, 53% male) and 107 memory research subjects (mean age 76 ± 6.6 years, 46% male), stroke patients had the lowest mean ± SD cognitive scores (MMSE score of 27.7 ± 1.84 and MoCA score of 22.9 ± 3.6), whereas TIA (MMSE score of 28.4 ± 1.7 and MoCA score of 24.9 ± 3.3) and memory subject scores (MMSE score of 28.5 ± 1.7 and MoCA score of 25.5 ± 3.0) were more similar. Rates of MoCA score of <26 in subjects with normal MMSE ( ≥27) were lowest in memory subjects, intermediate in TIA and highest after stroke (34 vs. 48 vs. 67%, p < 0.001). The cerebrovascular patients scored lower than the memory subjects on all MoCA frontal/executive subtests with differences being most marked in visuoexecutive function, verbal fluency and sustained attention (all p < 0.0001) and in stroke versus TIA (after adjustment for age and education). Stroke patients performed worse than TIA patients only on MMSE orientation in contrast to 6/10 subtests of the MoCA. Results were similar after restricting analyses to those with an MMSE score of ≥27. Conclusions: The MoCA demonstrated more differences in cognitive profile between TIA, stroke and memory research subjects without major cognitive impairment than the MMSE. The MoCA showed between-group differences even in those with normal MMSE and would thus appear to be a useful brief tool to assess cognition in those with MCI, particularly where the ceiling effect of the MMSE is problematic.

Objective — to analyze the results of screening for post‑stroke cognitive impairment (PCI) in patients with cerebral stroke (CS) admitted to the Stroke Center (SC) in different disease phases, and to determine independent predictors of the PCI persistence at discharge.&#x0D; Methods and subjects. 399 patients were enrolled, including 242 (60.7 %) men and 157 (39.3 %) women with the median age was 66.2 years (IQR 58.5 — 76.3). IS was diagnosed in 331 (82.9 %), and ICH in 68 (17.1 %) patients. Among patients with IS, 137 (41.4 %) had an atherothrombotic subtype, 152 (46.0 %) had a cardioembolic subtype, 21 (6.3 %) had a lacunar subtype, another 21 (6.3 %) had another or unknown cause of stroke. Patients were screened for PCI using the Mini‑Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) on admission and at discharge. Participants with MMSE score of 0 — 24 or a MoCA score of 0 — 25 were considered having PCI. Upon admission, all patients were assessed using the National Institutes of Health Stroke Scale (NIHSS), Bartel Index, and Modified Rankine Scale (mRS). The method of constructing and analyzing logistic regression models was used to determine independent predictors of the preservation of PCI at discharge. The analysis was carried out using the MedCalc v. 19.1.&#x0D; Results. The baseline NIHSS score ranged from 0 to 39 (median 11, IQR 6 — 18). The majority (64.2 %) of the subjects were hospitalized within the first 30 days from the CS onset. The MMSE score on admission ranged from 0 to 30 (median 20, IQR 2 — 27), and in 179 (44.9 %) of the patients the initial score was 0 to 17 (severe PCI), whereas in 61 (15 3 %) of the participants it was 18 to 24 (moderately severe PCI) and only 159 (39.8 %) persons scored 25 to 30 (no PCI). The baseline MoCA score ranged from 0 to 30 (median 15, IQR 1 — 24), and 356 (89.2 %) patients were shown to have PCI (score 0 to 25). According to screening with MMSE at discharge, 125 (31.4 %) patients had severe PCI, and 67 (16.8 %) had moderately severe PCI. The MoCA assessment before discharge indicated PCI in 324 (81.2 %) patients. According to both MMSE and MoCA, the rate of PCI on admission was significantly higher than at discharge (p &lt; 0.001). Among the 240 patients who had PCI according to MMSE score, 239 (99.6 %) had PCI according to the MoCA score. However, among 159 patients who screened negative for PCI with MMSE at admission, 117 (73.6 %) screened positive with MoCA. Screening results using both MMSE and MoCA were not significantly associated with affected hemisphere. ICH was associated with lower (p &lt; 0.0001) MMSE and MoCA scores compared with IS. Predictors of PCI according to MMSE score at discharge were a longer time interval from CS onset to SC admission, and a lower baseline MMSE score. However, with MoCA, the predictors were AT subtype IS, lesions in the distribution of the right or both middle cerebral arteries, older patient age, and a lower baseline MoCA score.&#x0D; Conclusions. In patients with MI, a high rate of PCI was documented on admission, but was significantly lower at discharge. In patients with established PCI, according to MMSE score, the use of MoCA for screening seems useless, however, screening with MoCA identified PCI in 3/4 in patients with a normal MMSE score. The independent predictors of scores on these two scales, indicating PCI, were significantly different, so they should not be considered interchangeable.

Abnormal MoCA and normal range MMSE scores in Parkinson disease without dementia: cognitive and neurochemical correlates.

Objective To compare the applicability of the Beijing Version of the Montreal Cognitive Assessment (MoCA) and the Mini Mental State Examination (MMSE) in screening for cognitive impairment in patients with acute ischemic stroke for 2-3 weeks. Methods MoCA and MMSE were conducted in 201 patients with acute ischemic stroke within 2 to 3 weeks after the onset of stroke. With MoCA<23 and MMSE<26 as the cut off value, we assessed the clinic effect of the MoCA and MMSE and explored the correlation between two instruments. Results The average scores of MoCA and MMSE scale were (20.5±4.3) and (25.4±3.5) points. The prevalence of cognitive impairment evaluated with MoCA and MMSE were 57.2% and 43.3%, respectively.MoCA showed significant correlation with MMSE score (Pearson's correlation coefficient=0.833, P<0.001), and an agreement with Kappa values of 0.532 (P<0.01) in screening for cognitive impairment. Conclusions The prevalence of cognitive impairment assessed with MoCA is higher than that of with MMSE when using MoCA<23 and MMSE<26 as the cut off values. Both instruments show a good agreement for screening cognitive impairment in acute ischemic stroke within 2 to 3 weeks following the disease onset. Key words: Acute ischemic stroke; Cognitive impairment; Montreal Cognitive Assessment (MoCA); Mini Mental State Examination (MMSE)

Objective To analyze the characteristics of cognitive function impairment in PD patients without dementia and their influencing factors, and provide evidence for early recognition and treatment of cognitive deficits in PD patients. Methods Fifty-six PD patients without dementia,admitted to our hospital from January 2010 to October 2011 were assessed with mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA) for cognitive function. Logistic stepwise regression was employed to analyze the influencing factors of cognitive function impairment.Results Using MMSE scores as the standard for recognition, PD patients with mild cognitive impairment (MCI) accounted for 7.14％ (6/56); however,using MoCA scores,they accounted for 71.43％(40/56). Both of the MMSE and MoCA scores were positively correlative with the education degree of the patients (r=0.483,P=-0.007; r=0.503,P=0.000).In the cognitive domain of MMSE,the scores of visuospatial function,and abilities of delayed recall,calculation,attention and repetition had significant decrement; and MMSE indicated that abilities of delayed recall, immediate memory, calculation and attention,and visuospatial function were main cognitive disturbances of PD.In the cognitive domain of MoCA,the scores of visuospatial and executive functions,and abilities of delayed recall,abstraction and repetition had significant decrement; MoCA indicated that visuospatial and executive functions,abilities of delayed recall,denomination,attention,abstraction and repetition were main cognitive disturbances of PD. Logistic regression analysis showed that education degree and clinical types were the main influencing factors of cognitive function impairment in PD patients. Conclusion Cognitive impairment is very common in patients with PD,and the main cognitive deficits involve visuospatial and executive functions,abilities of delayed recall,calculation,attention,abstraction and repetition; education degree and clinical types are the influencing factors of cognitive impairment of PD. Key words: Parkinson'sdisease; Cognitivefunctionimpairment; Montrealcognitive assessment

Objective To examine the application of Montreal Cognitive Assessment (MoCA) in Parkinson' s disease (PD) patients with normal general cognitive function by Mini-Mental State Examination (MMSE) evaluation.Methods PD patients were examined with MMSE, and those having a normal ageand education-adjusted MMSE score were included in the further study of MoCA testing.The patients with MoCA score not less than 26 were selected into normal control PD-NC group, and the patients with less than 26 into cognitive impaired PD-CI group.Scores of MoCA subtests were used in PD-CI group and PD-NC group to characterize cognitive changes in PD patients with mild cognitive impairment (MCI).MoCA score in PD-CI group used as dependent variable, and sex, educational level, age, course of disease, Hamilton Depression Rating Scale (HAMD), Hamilton Anxiety Rating Scale (HAMA), Self-rating depression Scale (SDS), Self-rating Anxiety Scale (SAS) and Unified Parkinson' s Disease Rating Scale (UPDRS) were used as independent variable, the risk factors of CI in PD patients was analysed by Linear Regression Analysis.Results There are 52.6% (112/213) PD patients with MMSE ≥ 26 while their MoCA < 26.Significant differences were observed in subtests of MoCA in visuospatial, executive, naming, attention,language, abstract, delayed recall and orientation between PD-CI group and PD-NC group (all P <0.01).Univariate and multivariate regression analysis showed that educational level is the most significant factor in PD-CI (OR:0.72, 95% CI 0.64-0.81, P < 0.05).Conclusions There is a high proportion of PD patients whose MMSE test showed normal but MoCA test showed cognitive impairment.MoCA examination was used to detect cognitive function of PD patients.Furthermore we suggest consider the education level in PD patients when evaluate their cognitive function. Key words: Parkinson disease; Cognition disorders; Neuropsychological tests; Mental status schedule

Objective: We aimed to establish the association of decline in cognitive screening tests scores, the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE), with the decline in neuropsychological diagnostic status from 3-6 months to a year later. Method: Patients with ischemic stroke/ Transient Ischemic Attack (TIA) received the MoCA and MMSE within 14 days after stroke, then 3-6 months and 1 year later. The decline in MoCA and MMSE scores were defined by reduction of 2 points or more in total scores, while stable/improved MoCA scores referred to reduction of MoCA scores less than 2 or improved scores. The decline in neuropsychological diagnostic status was defined by category transition from no cognitive impairment to any cognitive impairment (≥1 domain), from mild cognitive impairment (impairment in 1-2 domains) to moderate cognitive impairment (impairment &gt;2 domains) and dementia (i.e., functional loss associated with cognitive impairment, DSM-IV criteria), as well as from moderate cognitive impairment to dementia. Results: At baseline, most patients were Chinese (70.3%) and males (69.8%) with age of 59.8 ± 11.6 years and education of 7.7 ± 4.3 years. 327 out of 400 stroke/TIA patients completed neuropsychological assessments at 3-6 months and 275 completed at 1 year after their index cerebrovascular events. Of these, 31 (11.3%) had decline in neuropsychological diagnostic status. Logistic regression was used to model the association between probability of decline in neuropsychological diagnostic status and the decline in MMSE or MoCA scores. There were not significant associations between the decline of neuropsychological diagnostic status and the decline in MMSE scores. Controlling baseline MoCA scores and the change scores of MoCA from baseline to 3-6 months, patients with decline in MoCA scores (reduction of 2 points or more) were associated with higher risks of decline in neuropsychological diagnostic status, relative to those with stable/ improved MoCA scores (odd ratio=3.21, p=0.004). Conclusion: The decline in MoCA scores are associated with a higher risks for decline in neuropsychological diagnostic status from 3-6 months to 1 year, therefore may be used to detect post-stroke cognitive decline.

BackgroundScreening for cognitive function, using tests such as the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA), is the first step in detecting mild cognitive impairment (MCI) and dementia. However, the sensitivity of detecting MCI patients who will develop incident Alzheimer's disease (AD) dementia in the near future is low.ObjectiveThis study aimed to clarify the utility of the combination of the MMSE and MoCA in selecting patients at a high risk of incident AD dementia.MethodsIn this post-hoc analysis, we derived data from a Japanese observational registry of patients with vascular risk factors. The primary outcome was incident AD dementia. The accepted cutoff values of an MMSE score of 28 and an MoCA score of 26 for MCI were considered.ResultsAfter excluding those who did not undergo the test, 940 patients were included. During a median follow-up period of 4.6 years, incident AD dementia occurred in 49 patients. Patients diagnosed with MCI with MMSE scores <28 or MoCA scores <26 showed a significantly higher risk of AD dementia than those with normal MMSE or MoCA groups. However, patients who met the MCI criteria in only one test showed a risk similar to that of the normal group. In contrast, patients who met the MCI criteria for MMSE and MoCA scores had a 20.65-fold higher risk than those with normal MMSE and MoCA scores.ConclusionsPatients who met the MCI criteria for both the MMSE and MoCA were highly susceptible to incident AD dementia.Clinical Trial RegistrationUMIN000026671.

To examine Montreal Cognitive Assessment (MoCA) performance in patients with Parkinson's disease (PD) with "normal" global cognition according to Mini-Mental State Examination (MMSE) score. A cross-sectional comparison of the MoCA and the MMSE. Two movement disorders centers at the University of Pennsylvania and the Philadelphia Veterans Affairs Medical Center. A convenience sample of 131 patients with idiopathic PD who were screened for cognitive and psychiatric complications. Subjects were administered the MoCA and MMSE, and only subjects defined as having a normal age- and education-adjusted MMSE score were included in the analyses (N=100). As previously recommended in patients without PD, a MoCA score less than 26 was used to indicate the presence of at least mild cognitive impairment (MCI). Mean MMSE and MoCA scores+/-standard deviation were 28.8+/-1.1 and 24.9+/-3.1, respectively. More than half (52.0%) of subjects with normal MMSE scores had cognitive impairment according to their MoCA score. Impairments were seen in numerous cognitive domains, including memory, visuospatial and executive abilities, attention, and language. Predictors of cognitive impairment on the MoCA using univariate analyses were male sex, older age, lower educational level, and greater disease severity; older age was the only predictor in a multivariate model. Approximately half of patients with PD with a normal MMSE score have cognitive impairment based on the recommended MoCA cutoff score. These results suggest that MCI is common in PD and that the MoCA is a more sensitive instrument than the MMSE for its detection.

Early Cognitive Assessment Following Acute Stroke: Feasibility and Comparison between Mini-Mental State Examination and Montreal Cognitive Assessment

Recognition of early cognitive impairment in Parkinsons disease (PD) is important since it represents a risk factor for developing Parkinson's disease dementia and psychosis. The Mini- Mental State Examination (MMSE) remains the most commonly used screening instrument for global cognition, even though it has not been specifically validated for use in PD subjects. More recently, the Montreal Cognitive Assessment (MoCA) test has been recommended as a better screening tool in PD. Most of these studies have been done in countries with a highly-educated population. The objective of the study is to compare the performance between the MMSE and the MoCA to screen for mild cognitive impairment in subjects with Parkinson's disease and a low education background. The MMSE and MoCA were applied to 128 subjects using a cut-off score of 26 points for cognitive impairment. Fifty-five percent were classified with cognitive impairment according to the MoCA. Forty-one percent of subjects with a normal MMSE were classified with cognitive impairment by MoCA. Results from our analysis could be directly applied to other populations with a high proportion of poorly educated subjects.

Suitability of the Montreal Cognitive Assessment versus the Mini-Mental State Examination in Detecting Vascular Cognitive Impairment