What is the Montreal Cognitive Assessment Test?

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The Montreal Cognitive Assessment (MoCA) has been in the news lately thanks to President Trump. MoCA is a routine screening test for cognitive impairment in older adults that’s widely used by doctors in the United States. Although MoCA isn’t intended to prove or disprove definitively whether someone is experiencing problems with thinking or memory, it can be a helpful tool when used as part of an overall assessment by doctors trained to diagnose cognitive problems.

MoCA screens for all levels of cognitive impairment, or MCI. People with MCI have memory or thinking problems that aren’t serious enough to interfere with everyday living. MCI can be a precursor to Alzheimer’s disease or other kinds of dementia. However, MCI doesn’t always lead to dementia, and in some people, MCI can revert to normal cognition.

How the test works
MoCA is a 10-minute test designed to be administered by a healthcare provider who has been properly trained to use it. The test assesses a range of cognitive skills, including attention, concentration, executive functions, memory, language, calculation ability, and conceptual thinking.

Among the tasks people who take the test are asked to perform are:

  • Drawing a clock showing a certain time
  • Identifying drawings of three animals (a lion, a rhino, and a camel)
  • Recalling a list of five words (face, velvet, church, daisy, red)
  • Putting a list of digits in the proper ascending and descending numerical order
  • Copying a drawing of a three-dimensional cube
  • Counting back from 100 by sevens
  • Repeating two sentences verbatim
  • Naming as many words as possible that begin with the letter “F” in one minute (naming 11 or more gets a top score)

After a patient answers the questions, the provider calculates a score. A perfect score is 30, but a score of 26 or above is considered normal. Lower scores are associated with possible cognitive impairment.

Certain factors may interfere with screening test results. For example, scores may be affected by a patient’s education level, age, language ability, or the effects of medication they may be using at the time of the test.

Although many doctors rely on screening tests such as MoCA, routine screening of older adults for cognitive impairment isn’t recommended. In a report published in the February 25, 2020 issue of JAMA, the U.S. Preventive Services Task Force—a federal advisory panel of medical experts that evaluates and makes recommendations about preventive healthcare—concluded that there is insufficient evidence to recommend in favor of or against routine screening.

Just one of many screening tools
Mental status screening tests such as MoCA certainly have a place in identifying cognitive impairment and memory loss associated with dementia. However, organizations such as the Alzheimer’s Association recommend that doctors do a full medical workup because no single test can accurately diagnose dementia.

A full workup includes questions about medical history and current health conditions; a physical exam; a medication review; a discussion about mood, diet, and alcohol use; and a neurological exam, which evaluates coordination, balance, reflexes, mental status, and sensory and motor skills. Laboratory testing or brain imaging may also be recommended before a diagnosis is made.

Cognitive changes in older people aren’t always the result of dementia; other common causes include certain prescription drugs, vitamin deficiencies, or medical conditions such as depression, thyroid disease, anemia, diabetes, infection, and diseases of the kidney, liver, or heart.

A cognitive assessment should also include a discussion with family members, who can provide context about a person’s memory or behavior. Knowing whether a person’s memory or judgment has worsened over time is crucial for a doctor trying to diagnose any kind of cognitive decline.

Signs that someone should be assessed
Spouses or other family members are often the first to notice signs of cognitive decline in others. The following signs might be a hint that a family member needs to be assessed:

  • Losing or misplacing things such as keys more often than in the past
  • Struggling to think of the right words to express a thought or identify an object
  • Forgetting to keep appointments
  • Forgetting recent conversations or events
  • Changes in the ability to move
  • A decline in thinking skills, such as those involving time management or decision making
  • Feeling disoriented or getting lost in familiar places