Montreal Cognitive Assessment for Screening Mild Cognitive Impairment: Variations in Test Performance and Scores by Education in Singapore

Abstract

Background: The Montreal Cognitive Assessment (MoCA) was developed as a screening instrument for mild cognitive impairment (MCI). We evaluated the MoCA's test performance by educational groups among older Singaporean Chinese adults. Method: The MoCA and Mini-Mental State Examination (MMSE) were evaluated in two independent studies (clinic-based sample and community-based sample) of MCI and normal cognition (NC) controls, using receiver operating characteristic curve analyses: area under the curve (AUC), sensitivity (Sn), and specificity (Sp). Results: The MoCA modestly discriminated MCI from NC in both study samples (AUC = 0.63 and 0.65): Sn = 0.64 and Sp = 0.36 at a cut-off of 28/29 in the clinic-based sample, and Sn = 0.65 and Sp = 0.55 at a cut-off of 22/23 in the community-based sample. The MoCA's test performance was least satisfactory in the highest (>6 years) education group: AUC = 0.50 (p = 0.98), Sn = 0.54, and Sp = 0.51 at a cut-off of 27/28. Overall, the MoCA's test performance was not better than that of the MMSE. In multivariate analyses controlling for age and gender, MCI diagnosis was associated with a <1-point decrement in MoCA score (η² = 0.010), but lower (1-6 years) and no education was associated with a 3- to 5-point decrement (η² = 0.115 and η² = 0.162, respectively). Conclusion: The MoCA's ability to discriminate MCI from NC was modest in this Chinese population, because it was far more sensitive to the effect of education than MCI diagnosis.

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

“…use in different countries in Africa or the Middle East. A number of studies were not considered to display adequate sensitivity with high FP rates [29,50,51,54]. However, many of the studies indicated adequate to high sensitivity and specificity against study specific cut-offs and education adjustments.…”

“…Specificity ranged from 62% (at sensitivity of 75%) to 97% (at sensitivity of 91%). Two studies (N=489) specifically investigated the MoCA-Singapore [50,51] both adjusted cut-offs for education at different levels however accuracy levels were poor with high FP and FN. Sensitivity ranged from 54% (at a specificity of 51%) to 96% (at a specificity of 31%).…”

The Mini-Mental State Examination: Czech Norms and Cutoffs for Mild Dementia and Mild Cognitive Impairment due to Alzheimer's Disease

“…The MCI group was best differentiated from the NOS group at 27/28 or 29/30 points in two studies [5,30]. Interestingly, MMSE psychometric properties were similar to those from the Montreal Cognitive Assessment [5].…”

“…The MCI group was best differentiated from the NOS group at 27/28 or 29/30 points in two studies [5,30]. Interestingly, MMSE psychometric properties were similar to those from the Montreal Cognitive Assessment [5]. The best sensitivity and specificity between cognitively normal and mildly impaired individuals were observed for a threshold MMSE score of 28 points [30].…”

“…Thus, it is used in patients with the most common form of dementia, which is Alzheimer's disease (AD). Since the MMSE is a screening standard in clinical practice and research, several other instruments have been compared to the test around the world with similar diagnostic performance [3,4,5,6]. The MMSE has been modified several times.…”