Evaluation of the Mini-Mental State Examination and the Montreal Cognitive Assessment for Predicting Post-stroke Cognitive Impairment During the Acute Phase in Chinese Minor Stroke Patients

Abstract

Objective: To assess the value of the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) during acute phase in predicting post-stroke cognitive impairment (PSCI) at 3-6 months. Methods: We prospectively recruited 229 patients who had suffered their first-ever ischemic stroke. PSCI was determined in 104 of these patients by a comprehensive neuropsychological battery performed at 3-6 months. Receiver operating characteristic (ROC) curve analysis was then performed to compare the discriminatory ability of the MMSE and MoCA. Also, we applied a decision tree generated by the classification and regression tree methodology. Results: In total, 66 patients had PSCI when evaluated 3-6 months after the onset of minor stroke. Logistic regression analysis revealed that education, body mass index (BMI), and baseline MoCA scores were independently associated with PSCI. ROC curve analysis showed that the ability to predict PSCI was similar when compared between baseline MoCA scores [area under curve (AUC), 0.821; 95% confidence interval (CI), 0.743-0.898] and baseline MMSE scores (AUC, 0.809; 95% CI, 0.725-0.892, P = 0.75). Both MMSE and MoCA exhibited similar predictive values at their optimal cutoff points (MMSE ≤27; sensitivity, 0.682; specificity, 0.816; MoCA ≤21; sensitivity, 0.636; specificity, 0.895). Classification and regression tree-derived analysis yielded an AUC of 0.823 (sensitivity, 0.803; specificity, 0.842). Conclusion: When applied within 2 weeks of stroke, the MMSE and MoCA are both useful and have similar predictive value for PSCI 3-6 months after the onset of minor stroke.

Age-Dependent Association Between Elevated Homocysteine and Cognitive Impairment in a Post-stroke Population: A Prospective Study

“…Experienced neurological physicians, blinded to the baseline characteristics of the patients, evaluated the cognitive function of the patients using the Chinese version of the MMSE (27) at 1 month after stroke. The MMSE has been translated into Chinese and was validated for reliability and validity as a screening tool for cognitive impairment in the Chinese stroke population (28). The MMSE scores range from 0 to 30, with higher scores indicating better performance.…”

Current Update on the Clinical Utility of MMSE and MoCA for Stroke Patients in Asia: A Systematic Review

“…Four studies that compared the MMSE and MoCA showed equivalent sensitivity and specificity to identify PSCI [47][48][49][50]. However, only two studies [47,49] met the detection accuracy standard of 80% sensitivity and 60% specificity, as suggested by Stolwyk et al [14].…”

“…Detection accuracy improved after a processing speed test was added in the ROC analysis (sensitivity = 97-98%, specificity = 76-78%). Likewise, Zhu et al [50] reported poor sensitivity for both tests (MMSE = 68%, MoCA = 64%). Studies that found equivalent detection accuracy for the MMSE and MoCA also recruited older patients (see Table 1).…”

“…Despite the considerable education weightage on PSCI, only two studies stratified patients according to education in the ROC analysis [45,51]. The 12-year education cutoff for MoCA was found to be inadequate [53]; instead, a 6-year or primary education level cutoff better fit the Asian population [31,45,47,48,50,51]. Over half of the studies included in the review raised concerns over education's effect on MoCA scores (see Table 2).…”

“…Seven studies (64%) recruited patients with mild stroke or TIA, and eight studies (73%) excluded patients with aphasia. Less than half of the studies reported stroke location [44,47,48,50,53], and only one study reported stroke lateralization [50]. Only two studies did not report stroke severity [31,51], i.e., using the NIHSS (National Institutes of Health Stroke Scale) [54].…”