Cross-Cultural Applicability of the Montreal Cognitive Assessment (MoCA): A Systematic Review

Abstract

The MoCA is widely used to screen for mild cognitive impairment. While there are many available versions, the cross cultural validity of the assessment has not been explored sufficiently.We aimed to interrogate the validity of the MoCA in a cross-cultural context: in differentiating mild cognitive impairment (MCI) from normal controls (NC); and identifying cut-offs and adjustments for age and education where possible. This review sourced a wide range of studies including case-control studies. In addition, we report findings for differentiating dementias from NC and MCI from dementias, however, these were not considered to be an appropriate use of the MoCA.The subject of the review assumes heterogeneity and therefore meta-analysis/es was not conducted. Quality ratings, forest plots of validated studies (sensitivity and specificity) with covariates (suggested cut-offs, age, education and country) and summary received operating characteristic curve (sROC) are presented.The results showed a wide range in suggested cutoffs for MCI cross culturally, with variability in levels of sensitivity and specificity ranging from low to high. Poor methodological rigour appears to have affected reported accuracy and validity of the MoCA.The review highlights the necessity for cross cultural considerations when using the MoCA, and recognizing it as a screen and not a diagnostic tool. Appropriate cutoffs and point adjustments for education are suggested.2

Validation of the Czech Montreal Cognitive Assessment for Mild Cognitive Impairment due to Alzheimer Disease and Czech Norms in 1,552 Elderly Persons

“…Thirdly, many other studies observed the same or close cutoff scores between 22 and 24 points for MCI in different languages, countries, and cohorts [3, 18, 20, 22, 23, 26, 33, 43]. This is in line with the conclusion and findings of recent reviews that thresholds lower than 26 are likely to be more useful for optimal diagnostic accuracy [9, 18, 25, 43].…”

“…This is in line with the conclusion and findings of recent reviews that thresholds lower than 26 are likely to be more useful for optimal diagnostic accuracy [9, 18, 25, 43]. …”

“…We hope that we contributed to an ongoing international discussion to lower the cutoff from the originally recommended score of 26 points to the approximately 23–24 points found in our study and other studies [9, 18, 25, 43]. We also present reference values of the Czech MoCA-CZ stratified by age and education influencing total scores.…”

Current approaches to dementia screening and case finding in low‐ and middle‐income countries: Research update and recommendations

“…Adapting cognitive assessment instruments from HICs to LMIC settings has been criticized as this typically introduces cultural, educational, and literacy biases increasing the risk of misclassification and an overestimation of dementia prevalence . It is further noted that some widely adapted measures lack rigorous psychometric validation across different LMIC settings …”

“…Low levels of education and literacy have been found to affect performance on numerous cognitive domains including the following: reading, writing, drawing, memory, visual perception, language, verbal fluency, calculating, and reasoning . They also influence brief assessment measures of global cognitive function, including the MMSE, Montreal Cognitive Assessment (MoCa), Addenbrooke's Cognitive Examination (ACE), Clock Drawing Test (CDT), Mini Cog, and 7 Minute Screening, as highlighted from studies conducted in Asia, South America, Africa, and the Middle East . However, some measures, for example, the Rowland Universal Dementia Assessment Scale (RUDAS) that was developed to assess dementia in multicultural populations in Australia, do not require the person to be able to read or write and are less influenced by education compared with other instruments such as the MMSE .…”