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Montreal Cognitive Assessment (MoCA)
Availability
Please visit this website for more information about the instrument: Montreal Cognitive Assessment

 
Universities/Foundations/Health Professionals/Hospitals/Clinics/Public Health Institutes:
MoCA may be used, reproduced, and distributed, WITHOUT prior written permission.
 
Written permission and Licensing Agreement is required if funded by commercial entity or pharma.
 
Permission may be requested by filling out form at https://mocacognition.com/permission/
 
Commercial Entity/Pharma:
MoCA may be used, reproduced, and distributed, WITH prior written permission and Licensing Agreement. https://mocacognition.com/permission/.
 
To administer the test, certification of training and qualification is required from the publisher (training takes 1 hour).  
Classification
Core: Parkinson's Disease (PD)
Recommendations for use: Recommended as a global screening instrument to identify individuals with cognitive impairment and not as an assessment tool used to determine the severity of cognitive impairment.
 
NeuroRehab Supplemental - Highly Recommended
Recommendations for use: Indicated for studies requiring a cognitive screening measure.
 
Supplemental - Highly Recommended: Epilepsy, Huntington's Disease (HD), Subarachnoid Hemorrhage (SAH), Stroke (based on study type, disease stage and disease type), and Unruptured Cerebral Aneurysms
 
Supplemental: Mitochondrial Disease (Mito)
Short Description of Instrument
Purpose: The MoCA was designed to efficiently screen for mild to moderate cognitive impairment, including patients with normal mini-mental state examination (MMSE). In Parkinson's disease it is the better instrument to screen for Mild Cognitive Impairment (PD-MCI) and the only one associated with progression to PD dementia (PDD) (Kim et al., 2019; Mazancova et al., 2020). This supports its use to screen for cognition in this patient population.
 
Overview: The MoCA is a screening test of cognition with favorable psychometric properties. It screens eight domains: Visuospatial/executive, Naming, Memory, Attention, Language, Abstraction, Delayed recall, and Orientation. Alternate forms are available to mitigate practice effects across serial assessments.
 
Time: The assessment takes approximately 10 minutes.
 
Language: The MoCA is available as either a paper or electronic application test. The paper test is available in nearly 100 languages, though not all language versions have undergone rigorous validation.
Comments/Special Instructions
To access the MoCA:
        • Create a MoCA account.

        • Download either the paper or app test.

        • Take the Training & Certification program*.

 
 *Since September 1st, 2019, training and certification has become mandatory to administer and score the MoCA Test for clinical, research and educational use. Only certified users will be able to access the test. (Nasreddine, 2020)
 
The MoCA can be administered remotely via abbreviated telephone version or full version via audio-visual conference (i.e., Skype, FaceTime or Teleconference) (Pendlebury et al., 2013; Wong et al., 2015, 2018).
 
NeuroRehab-Specific: Normative data is most available for older adults, but the MoCA has been increasingly studied in various neurological conditions, across adulthood.
Scoring and Psychometric Properties
Scoring: The total possible score is 30 points (total for each domain: Visuospatial/executive - 5, Naming - 3, Memory - None, Attention - 6, Language - 3, Abstraction - 2, Delayed recall - 5, Orientation - 6). One point is added for an individual who has 12 years or fewer of formal education; however, the total possible score remains the same. The cued recall and memory recognition trials do not contribute to the total score. Higher scores indicate better performance.
 
The original suggested cut-off score was any score less than 26 for differentiating healthy aging from Mild Cognitive Impairment. A recent meta-analysis indicated that a score of 23 was more valid, resulting in fewer false positives (Carson et al., 2018). A range of cut-off scores have been proposed for different settings, neurological conditions (Brown et al., 2016; Mazancova et al., 2020) and languages.
 
For PD-MCI and PDD different cutoffs have been proposed: Dalrymple-Alford et al. (2010): PD-MCI <26 (0.90 sensitivity, 0.75 specificity), PDD <21 (0.81, 0.95) (vs. PD normal cognition).
 
Psychometric Properties: There have been strong validation studies emerging across patient populations (e.g., cerebrovascular, MCI/AD, Parkinson's disease). The remotely administered MoCA versions have also been validated across patient populations.
Rationale/Justification
Strengths: The MoCA is less affected by ceiling effects than the MMSE. The MoCA includes items that are sensitive to executive dysfunction and focal cognitive deficits and may therefore better detect cognitive impairment in certain neurological conditions compared to the MMSE (e.g., Pendlebury et al., 2012). In PD it has been validated for remote (Abdolahi et al., 2016; DeYoung et al., 2019; Lindauer, 2017) and telephone administration (Benge, 2021).
 
MoCA<26 is strongly predictive of cognitive decline over the following two years (hazard ratio 3.47) (Kandiah et al., 2014), but see Lessig et al. (2012) who found MoCA to not change significantly up to 3 years.
 
Responsiveness in PD to treatment with creatine+coQ-10 (Li et al., 2015), donepezil (Gu et al., 2015), rivastigmine (Li et al., 2015) and computerized cognitive training (Bernini et al., 2020) has been shown but some studies failed to find treatment effects with rivastigmine (Mamikonyan et al., 2015) or rasagiline (Weintraub et al., 2016).
 
The MoCA has demonstrated good test-retest (0.79) and inter-rater reliability (0.81), and convergent validity (correlation with neuropsychological test battery composite score r=0.72) in PD (Gill et al., 2008)
 
Weaknesses: Not all test versions (abbreviated, non-English language forms, alternate forms) have been rigorously validated. Reliable change scores for serial assessment have not been well-established for all test-retest timeframes and neurological conditions. MoCA performance is markedly affected by aphasia, and in some disorders, it has limited sensitivity to milder cognitive impairments.
References
Key Reference:
Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9.
 
Additional References:
Iiboshi K, Yoshida K, Yamaoka Y, Eguchi Y, Sato D, Kishimoto M, Funaki K, Mimura M, Kishimoto T. A Validation Study of the Remotely Administered Montreal Cognitive Assessment Tool in the Elderly Japanese Population. Telemed J E Health. 2020 Jul;26(7):920-28.
 
Lindauer A, Seelye A, Lyons B, Dodge HH, Mattek N, Mincks K, Kaye J, Erten-Lyons D. Dementia Care Comes Home: Patient and Caregiver Assessment via Telemedicine. Gerontologist. 2017 Oct 1;57(5):e85-e93.
 
Luis CA, Keegan AP, Mullan M. Cross validation of the Montreal Cognitive Assessment in community dwelling older adults residing in the Southeastern US. Int J Geriatr Psychiatry. 2009 Feb;24(2):197-201.
 
Nasreddine ZS. MoCA Test Mandatory Training and Certification: What Is the Purpose? J Am Geriatr Soc. 2020 Feb;68(2):444-45.
 
Naugle RI, Kawczak K. Limitations of the Mini-Mental State Examination. Cleve Clin J Med. 1989 May;56(3):277-81.
 
Pendlebury ST, Cuthbertson FC, Welch SJ, Mehta Z, Rothwell PM. Underestimation of cognitive impairment by Mini-Mental State Examination versus the Montreal Cognitive Assessment in patients with transient ischemic attack and stroke: a population-based study. Stroke. 2010 Jun;41(6):1290-3.
 
Pendlebury ST, Markwick A, de Jager CA, Zamboni G, Wilcock GK, Rothwell PM. Differences in cognitive profile between TIA, stroke and elderly memory research subjects: a comparison of the MMSE and MoCA. Cerebrovasc Dis. 2012;34(1):48-54.
 
Pendlebury ST, Welch SJ, Cuthbertson FC, Mariz J, Mehta Z, Rothwell PM. Telephone assessment of cognition after transient ischemic attack and stroke: modified telephone interview of cognitive status and telephone Montreal Cognitive Assessment versus face-to-face Montreal Cognitive Assessment and neuropsychological battery. Stroke. 2013 Jan;44(1):227-9.
 
Popovic IM, Seric V, Demarin V. Mild cognitive impairment in symptomatic and asymptomatic cerebrovascular disease. J Neurol Sci. 2007 Jun 15;257(1-2):185-93.
 
Wong A, Nyenhuis D, Black SE, Law LS, Lo ES, Kwan PW, Au L, Chan AY, Wong LK, Nasreddine Z, Mok V. Montreal Cognitive Assessment 5-minute protocol is a brief, valid, reliable, and feasible cognitive screen for telephone administration. Stroke. 2015 Apr;46(4):1059-64.
 
Wong A, Yiu S, Nasreddine Z, Leung KT, Lau A, Soo YOY, Wong LK, Mok V. Validity and reliability of two alternate versions of the Montreal Cognitive Assessment (Hong Kong version) for screening of Mild Neurocognitive Disorder. PLoS One. 2018 May 23;13(5):e0196344.
 
Zadikoff C, Fox SH, Tang-Wai DF, Thomsen T, de Bie RM, Wadia P, Miyasaki J, Duff-Canning S, Lang AE, Marras C. A comparison of the mini mental state exam to the Montreal cognitive assessment in identifying cognitive deficits in Parkinson's disease. Mov Disord. 2008 Jan 30;23(2):297-9.
 
Parkinson's Disease-Specific References:
Abdolahi A, Bull MT, Darwin KC, Venkataraman V, Grana MJ, Dorsey ER, Biglan KM. A feasibility study of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders. Health Informatics J. 2016 Jun;22(2):304-11.
 
Benge JF, Kiselica AM. Rapid communication: Preliminary validation of a telephone adapted Montreal Cognitive Assessment for the identification of mild cognitive impairment in Parkinson's disease. Clin Neuropsychol. 2021 Jan;35(1):133-47.
 
Brown DS, Bernstein IH, McClintock SM, Munro Cullum C, Dewey RB Jr, Husain M, Lacritz LH. Use of the Montreal Cognitive Assessment and Alzheimer's Disease-8 as cognitive screening measures in Parkinson's disease. Int J Geriatr Psychiatry. 2016 Mar;31(3):264-72.
 
Carson N, Leach L, Murphy KJ. A re-examination of Montreal Cognitive Assessment (MoCA) cutoff scores. Int J Geriatr Psychiatry. 2018 Feb;33(2):379-88.
 
Chapman JE, Cadilhac DA, Gardner B, Ponsford J, Bhalla R, Stolwyk RJ. Comparing face-to-face and videoconference completion of the Montreal Cognitive Assessment (MoCA) in community-based survivors of stroke. J Telemed Telecare. 2021 Sep;27(8):484-92.
 
Ciesielska N, Sokolowski R, Mazur E, Podhorecka M, Polak-Szabela A, Kedziora-Kornatowska K. Is the Montreal Cognitive Assessment (MoCA) test better suited than the Mini-Mental State Examination (MMSE) in mild cognitive impairment (MCI) detection among people aged over 60? Meta-analysis. Psychiatr Pol. 2016 Oct 31;50(5):1039-52. English, Polish.
 
Dalrymple-Alford JC, MacAskill MR, Nakas CT, Livingston L, Graham C, Crucian GP, Melzer TR, Kirwan J, Keenan R, Wells S, Porter RJ, Watts R, Anderson TJ. The MoCA: well-suited screen for cognitive impairment in Parkinson disease. Neurology. 2010 Nov 9;75(19):1717-25.
 
DeYoung N, Shenal BV. The reliability of the Montreal Cognitive Assessment using telehealth in a rural setting with veterans. J Telemed Telecare. 2019 May;25(4):197-203.
 
Gill DJ, Freshman A, Blender JA, Ravina B. The Montreal cognitive assessment as a screening tool for cognitive impairment in Parkinson's disease. Mov Disord. 2008 May 15;23(7):1043-46.
 
Kim HM, Nazor C, Zabetian CP, Quinn JF, Chung KA, Hiller AL, Hu SC, Leverenz JB, Montine TJ, Edwards KL, Cholerton B. Prediction of cognitive progression in Parkinson's disease using three cognitive screening measures. Clin Park Relat Disord. 2019;1:91-7.
 
Mazancova AF, Ru?icka E, Jech R, Bezdicek O. Test the Best: Classification Accuracies of Four Cognitive Rating Scales for Parkinson's Disease Mild Cognitive Impairment. Arch Clin Neuropsychol. 2020 Jul 17:acaa039.
 
Weintraub D, Hauser RA, Elm JJ, Pagan F, Davis MD, Choudhry A; MODERATO Investigators. Rasagiline for mild cognitive impairment in Parkinson's disease: A placebo-controlled trial. Mov Disord. 2016 May;31(5):709-14.
 
SAH-Specific References:
Schweizer TA, Al-Khindi T, Macdonald RL. Mini-Mental State Examination versus Montreal Cognitive Assessment: rapid assessment tools for cognitive and functional outcome after aneurysmal subarachnoid hemorrhage. J Neurol Sci. 2012 May 15;316(1-2):137-40.
 
Wong GK, Lam SW, Wong A, Ngai K, Poon WS, Mok V. Comparison of montreal cognitive assessment and mini-mental state examination in evaluating cognitive domain deficit following aneurysmal subarachnoid haemorrhage. PLoS One. 2013;8(4):e59946.
 
Huntington's Disease-Specific References:
Mickes L, Jacobson M, Peavy G, Wixted JT, Lessig S, Goldstein JL, Corey-Bloom J. A comparison of two brief screening measures of cognitive impairment in Huntington's disease. Mov Disord. 2010 Oct 15;25(13):2229-33.
 
Videnovic A, Bernard B, Fan W, Jaglin J, Leurgans S, Shannon KM. The Montreal Cognitive Assessment as a screening tool for cognitive dysfunction in Huntington's disease. Mov Disord. 2010 Feb 15;25(3):401-4.
 
Stroke-Specific References:
Cumming TB, Churilov L, Linden T, Bernhardt J. Montreal Cognitive Assessment and Mini-Mental State Examination are both valid cognitive tools in stroke. Acta Neurol Scand. 2013 Aug;128(2):122-9.
 
Dong Y, Sharma VK, Chan BP, Venketasubramanian N, Teoh HL, Seet RC, Tanicala S, Chan YH, Chen C. The Montreal Cognitive Assessment (MoCA) is superior to the Mini-Mental State Examination (MMSE) for the detection of vascular cognitive impairment after acute stroke. J Neurol Sci. 2010 Dec 15;299(1-2):15-8.
 
Potocnik J, Ovcar Stante K, Rakusa M. The validity of the Montreal cognitive assessment (MoCA) for the screening of vascular cognitive impairment after ischemic stroke. Acta Neurol Belg. 2020 Jun;120(3):681-85.
 
Mitochondrial Disease-Specific References:
Apaijai N, Sriwichaiin S, Phrommintikul A, Jaiwongkam T, Kerdphoo S, Chansirikarnjana S, Thongmung N, Mahantassanapong U, Vathesatogkit P, Kitiyakara C, Sritara P, Chattipakorn N, Chattipakorn SC. Cognitive impairment is associated with mitochondrial dysfunction in peripheral blood mononuclear cells of elderly population. Sci Rep. 2020 Dec 8;10(1):21400.
 
van de Loo KFE, van Zeijl NT, Custers JAE, Janssen MCH, Verhaak CM. A conceptual disease model for quality of life in mitochondrial disease. Orphanet J Rare Dis. 2022 Jul 15;17(1):263.
 
Zhang G, Hou Y, Wang Z, Ye Z. Cognitive Profile of Patients With Mitochondrial Chronic Progressive External Ophthalmoplegia. Front Neurol. 2020 Jan 29;11:36.
 
Document last updated March 2024