Which cut-off value of the Montreal Cognitive Assessment should be used for post-stroke cognitive impairment? A systematic review and meta-analysis of studies on diagnostic test accuracy.

Abstract

Post-stroke cognitive impairment (PSCI) is one of the serious complications of stroke. The Montreal Cognitive Assessment (MoCA), as a brief cognitive impairment screening tool, is widely used in stroke survivors. However, some studies have suggested that the use of the universal cut-off value of 26 may be inappropriate for detecting cognitive impairments in stroke settings. We conducted this study to identify the optimal cut-off value of the MoCA in screening for PSCI. PubMed, CINAHL, Embase, the Cochrane Library, and Web of Science were searched for eligible studies until March 23, 2023. All studies were screened by two independent researchers. The quality of each article was evaluated by the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate mixed effects model was used to pool sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and the summary receiver operating characteristic curve. 24 studies with a total of 4,231 patients were included in this review. Despite the lack of evidence of publication bias, a high degree of heterogeneity was observed. Meta-analysis revealed that a cut-off value of 21/22 yielded the best diagnostic accuracy. The optimal cut-off varied in different regions, stroke types, and stroke phases as well. The optimal cut-off of MoCA was 21/22 for stroke populations rather than the initially recommended cut-off of 26. A revised (lower) cut-off should be considered for stroke survivors.