BRIEF METHODOLOGICAL REPORTS

The Montreal Cognitive Assessment, MoCA: A Brief Screening

Tool For Mild Cognitive Impairment
Ziad S. Nasreddine, MD, wz Natalie A. Phillips, PhD, z z Valerie Bedirian, BSc,#
Simon Charbonneau, MPS,# Victor Whitehead, MSW, z Isabelle Collin, PhD,
Jeffrey L. Cummings, MD, ww and Howard Chertkow, MDz k

OBJECTIVES: To develop a 10-minute cognitive screening RESULTS: Using a cutoff score 26, the MMSE had a sen-
tool (Montreal Cognitive Assessment, MoCA) to assist first- sitivity of 18% to detect MCI, whereas the MoCA detected
line physicians in detection of mild cognitive impairment 90% of MCI subjects. In the mild AD group, the MMSE
(MCI), a clinical state that often progresses to dementia. had a sensitivity of 78%, whereas the MoCA detected
DESIGN: Validation study. 100%. Specificity was excellent for both MMSE and MoCA
SETTING: A community clinic and an academic center. (100% and 87%, respectively).
PARTICIPANTS: Ninety-four patients meeting MCI clin- CONCLUSION: MCI as an entity is evolving and some-
ical criteria supported by psychometric measures, 93 pa- what controversial. The MoCA is a brief cognitive screen-
tients with mild Alzheimers disease (AD) (Mini-Mental ing tool with high sensitivity and specificity for detecting
State Examination (MMSE) score
17), and 90 healthy MCI as currently conceptualized in patients performing
elderly controls (NC). in the normal range on the MMSE. J Am Geriatr Soc
53:695699, 2005.
MEASUREMENTS: The MoCA and MMSE were admin-
istered to all participants, and sensitivity and specificity Key words: MoCA; mild cognitive impairment; Alz-
of both measures were assessed for detection of MCI heimers; cognitive assessment
and mild AD.

From the Center for Clinical Research, Neurology Service, Hopital Charles
LeMoyne, Quebec, Canada; wMemory Clinic Neuro Rive-Sud, Universite de
Sherbrooke, Quebec, Canada; zBloomfield Center for Research in Aging,
Lady Davis Institute, and Department of Clinical Neurosciences and
M ild cognitive impairment (MCI) is an intermediate
clinical state between normal cognitive aging and
dementia, and it precedes and leads to dementia in many
Division of Geriatric Medicine, Sir Mortimer B. DavisFJewish General
Hospital, McGill University and Division of Geriatric Medicine, Montreal,
cases. Neuropsychological, neuropathological, and imag-
Quebec, Canada; kResearch Center, University Institute of Geriatrics, Uni- ing studies also support MCIs transitional nature.1 The
versity of Montreal, Montreal, Quebec, Canada; zCenter for Research in concept of MCI is new, evolving, and somewhat contro-
Human Development/Department of Psychology, Concordia University, versial, but there is rough consensus as to its clinical def-
Montreal, Quebec, Canada; #Department of Psychology, University of Que-
bec at Montreal, Montreal, Quebec, Canada; Departments of Neurology
inition and prognosis, and it is a common and important
and wwPsychiatry and Biobehavioral Sciences, David Gellen School of Med- condition.2 Neuropsychological testing with standardized
icine, University of California at Los Angeles, Los Angeles, California. tests is often used to assess and characterize MCI pa-
This work was supported by the Canadian Institutes for Health Research, tients,2,3 but many clinicians lack easy and timely access to
Societe Alzheimer Rive-Sud, Longueuil, Quebec, Alzheimer Society of such assessments or to tertiary care memory clinics. Acces-
Canada, Valorization Recherche Quebec (Consortium Cognition et sibility will become even more of a problem in coming years
Vieillissement), and Consortium of Canadian Centers for Clinical
Cognitive Research.
given the substantial increase in the proportion of elderly in
the population.
Dr. Chertkow is a national researcher of the Fonds de la recherche en Sante du
Quebec. Dr. Jeffrey L. Cummings is supported by a National Institute on Although several screening instruments are available
Aging Alzheimers Disease Center grant (AG 16570), an Alzheimers disease for detecting dementia, the Mini-Mental State Examination
Research Center of California grant, and the Sidell-Kagan Foundation. (MMSE)4 is the most widely used by frontline physicians.
Corresponding authors: Dr. Ziad S. Nasreddine, MD, FRCP(C), Neuro Rive- Difficulties with the MMSE in detecting early dementia
Sud Memory Clinic, 4896 Taschereau Boulevard Suite 250, Greenfield Park, have been reported.57 Most individuals meeting clinical
Quebec, Canada, J4V 2J2. E-mail: ziadn@sympatico.ca
Dr. Howard Cherthow, MD, FRCP(C), Sir Mortimer B. Davis, Jewish
criteria for MCI score above 26 on the MMSE, which is also
General Hospital, 3755 Chemin de la Cote-Sainte-Catherine, Montreal, the range for normal elderly individuals. Family physicians
Quebec, Canada, H3T 1E2. E-mail: howard.chertkow@mcqill.ca are left with no clearly accepted and easily administered

JAGS 53:695699, 2005

r 2005 by the American Geriatrics Society 0002-8614/05/$15.00
696 NASREDDINE ET AL. APRIL 2005VOL. 53, NO. 4 JAGS

tool to evaluate MCI. To address this problem, the Mon- The MCI group consisted of 94 elderly participants.
treal Cognitive Assessment (MoCA) was developed as a MCI in these centers is a clinically oriented diagnostic label
tool to screen patients who present with mild cognitive (as is dementia), applied after evaluation by trained neu-
complaints and usually perform in the normal range on the rologists or geriatricians and a standardized mental status
MMSE. This study assessed the sensitivity and specificity of battery. The definition of MCI corresponded to previously
the MoCA in patients with MCI and Alzheimers disease established criteria.1,810 This studys criteria, reviewed
(AD) and normal elderly controls. previously2 and adapted from a previous study,8 included
the presence of subjective complaints of gradual memory
METHODS loss over at least 6 months reported by the patient or family
members. There had to be objective evidence of memory
MoCA Development loss demonstrated on clinical memory tests administered by
The MoCA was developed based on the clinical intuition of the physician. There had to be general preservation of other
one of the authors (ZN) regarding domains of impairment cognitive domains, although subtle changes in other do-
commonly encountered in MCI and best adapted to a mains were present in 35% of cases. There was preserved
screening test. An initial version covered 10 cognitive do- functioning in terms of activities of daily living, with only
mains using rapid, sensitive, and easy-to-administer cogni- mild if any impairment in instrumental activities (e.g.,
tive tasks. Iterative modification of the MoCA took place keeping memory lists). There had to be absence of other
over 5 years of clinical use. An initial test version was ad- obvious medical, neurological, or psychiatric explanation
ministered to 46 consecutive patients (mostly diagnosed for the memory loss (with the exception of mild depression)
with MCI or AD) presenting to the University of Sher- and insufficient findings to warrant a clinical diagnosis of
brooke Neuro Rive-Sud (NRS) memory clinic with cogni- dementia.9 This bedside assessment was later supported by
tive complaints, a MMSE score of 24 or higher, and performance on neuropsychological tests of delayed mem-
impaired neuropsychological assessment. They were com- ory (Rey Auditory Verbal Learning Test11 and Delayed
pared with 46 healthy controls from the same community Visual Reproduction and Logical Memory, two subtests of
with normal neuropsychological performance. Five items the Wechsler Memory Scale12). Four subjects had mild
did not discriminate well and were replaced. Scoring was memory loss according to these tests, as well as impairment
then adjusted, giving increased weight to the most discri- in multiple other cognitive domains. Ninety subjects had
minant items. The current study used this final revised ver- primarily memory loss, below normative values on age- and
sion of the MoCA, now covering eight cognitive domains. education-adjusted norms on at least one of these three tests
(at least a 1.0standard deviation (SD) decrease in all cases
Evaluation of the MoCA in AD and MCI and a 1.5-SD decrease in 85/90 cases). No subjects were
judged as having preserved memory.
In the current study, three participant groups were recruit-
The AD group consisted of 93 participants with a di-
ed: patients with mild AD, patients meeting criteria for
agnosis of probable AD meeting the Diagnostic and Statis-
MCI, and normal elderly controls (NC). The MoCA was
tical Manual of Mental Disorders, Fourth Edition,
administered to all groups, and its sensitivity and specificity
criteria13 and the National Institute of Neurological and
were compared with those of the MMSE for detection of
Communicative Disorders and Stroke/Alzheimers Disease
MCI and mild AD, with clinical diagnosis in a memory
and Related Disorders Association criteria.14 These indi-
clinic (supported by neuropsychological evaluation) as the
viduals were all mildly demented, and all but three had
criterion standard. The MoCA was administered in French
MMSE scores of 17 or greater. The MoCA was not used to
and English as appropriate. The French version is identical
make a diagnosis of MCI or AD and was collected inde-
to the English version except for the sentences used in the
pendently of the diagnostic assessments.
repetition task.
The NC group consisted of 90 healthy elderly volun-
teers recruited from the community, with no memory or
Study Participants cognitive complaints and normal baseline neuropsycholog-
The three groups were recruited from the Jewish General ical performance. A subset (n 5 51) also had a neurological
Hospital (JGH) Memory Clinic in Montreal, a tertiary care examination and computed tomography scan, which were
referral center, and the University of Sherbrooke NRS normal.
memory clinic in a south-shore community of Montreal. Demographic information is summarized in Table 1.
The review board of both institutions approved the study The JGH and NRS groups were similar except that the NRS
protocol. group was largely French speaking (87%) and the JGH

Table 1. Subject Demographics

Age Education
Characteristic Average  Standard Deviation Female n (%)

Controls (n 5 90) 72.84  7.03 13.33  3.40 54 (60)

Mild cognitive impairment (n 5 94) 75.19  6.27 12.28  4.32 41 (44)
Alzheimers disease (n 5 93) 76.72  8.83 10.03  3.84 55 (59)

Po.05.
JAGS APRIL 2005VOL. 53, NO. 4 MOCA: A BRIEF SCREENING TOOL FOR MCI 697

group was English speaking (100%). After adjusting 0.9  2.5 points, and correlation between the two evalua-
for education (the French sample had fewer years of tions was high (correlation coefficient 5 0.92, Po.001).
education), the two language subsamples obtained equiv- The internal consistency of the MoCA was good, yield-
alent scores on the MMSE and MoCA in each of the three ing a Cronbach alpha on the standardized items of 0.83.
diagnostic groups. Item analysis revealed that the following items discrimi-
AD participants were significantly older than MCI and nated reliably between all three groups, with the AD par-
NC participants (F2,272 5 6.26, mean squared error ticipants performing most poorly, followed by the MCI
(MSE) 5 55.56, P 5.002), but the latter two groups did participants: trail making, cube drawing, clock drawing,
not differ from each other. Mean years of education also naming, delayed recall, phonemic fluency, abstraction, and
differed, F2,271 5 17.30, MSE 5 15.00, Po.001), with the orientation. The following tasks discriminated the AD par-
AD participants having significantly less education than the ticipants from the MCI participants and NCs, who did not
NC or MCI participants. Again, the MCI and NC groups differ from each other: digit span, sustained attention, and
did not differ from each other. the serial 7 calculation task. These tasks test attentional
processes, which appeared to be largely preserved in the
Cognitive Testing MCI sample. Finally, the AD and MCI participants per-
formed similarly poorly on the sentence repetition task.
The MMSE, the MoCA, and the same neuropsychological
Thus, all items were successful in discriminating between at
battery were administered to all groups in both institutions.
least two of the groups, and the majority discriminated be-
The MMSE and MoCA were administered on the same day
tween all three groups in a stepwise fashion. Delayed recall
or within 3 months for all participants except four, for
was the most impaired item in MCI participants.
whom administration was less than 12 months apart.

Montreal Cognitive Assessment Group Differences and Sensitivity and Specificity of the
MMSE and MoCA
The final version of the MoCA (available at www.mocatest.
org) is a one-page 30-point test administered in 10 minutes. Initial analyses indicated that persons with 12 years of ed-
Details on the specific MoCA items are as follows. The ucation or less tended to have worse performance on the
short-term memory recall task (5 points) involves two MoCA. To correct for education effects, 1 point was added
learning trials of five nouns and delayed recall after ap- for participants with 12 years of education or less on their
proximately 5 minutes. Visuospatial abilities are assessed total MoCA score (if o30). Figure 1 shows the education-
using a clock-drawing task (3 points) and a three-dimen- adjusted mean MMSE and MoCA scores of NC, MCI, and
sional cube copy (1 point). Multiple aspects of executive AD participants. Average MMSE scores of all three groups
functions are assessed using an alternation task adapted differed significantly from each other (F2,272 5 166.20,
from the Trail Making B task (1 point), a phonemic fluency MSE 5 5.40, Po.001). Average MoCA scores also differed
task (1 point), and a two-item verbal abstraction task (2 significantly between the three groups (F2,274 5 232.91,
points). Attention, concentration, and working memory are MSE 5 12.84, Po.001) and remained significant after con-
evaluated using a sustained attention task (target detection trolling for the effects of age and education (analysis of
using tapping; 1 point), a serial subtraction task (3 points), covariance F2,269 5 183.32, MSE 5 11.18, Po.001). As
and digits forward and backward (1 point each). Language seen in Figure 1, the differences between the groups were
is assessed using a three-item confrontation naming task much more pronounced using the MoCA than the MMSE,
with low-familiarity animals (lion, camel, rhinoceros; 3 and the mean score of the MCI participants fell within the
points), repetition of two syntactically complex sentences (2 normal range on the MMSE and in the abnormal range on
points), and the aforementioned fluency task. Finally, ori-
entation to time and place is evaluated (6 points). 30 NC
MCI
AD
RESULTS
25
Psychometric Properties of the MoCA
To determine whether the French and English versions of
the MoCA were equivalent, Francophone and Anglophone
participants matched on age and who had 11 or more years 20
of education were selected for each clinical group. MoCA
scores did not differ significantly between Francophone and
Anglophone participants when collapsed over clinical 15
group (t (172) 5 0.12, P 5.91; Francophone mean  SD 5
23.6  6.4; Anglophone 5 23.7  4.1), or when the three
clinical groups were considered separately (all to2.1, all
P4.06). Therefore, results from the two centers and the 10
MMSE MoCA
two languages of testing were collapsed for analyses.
Test-retest reliability data were collected from a sub- Figure 1. Mean Mini-Mental State Examination (MMSE) and
sample of 26 participants (patients and controls) tested, on Montreal Cognitive Assessment (MoCA) scores  standard de-
average, 35.0  17.6 days apart. The mean change in viations for normal controls (NCs) and subjects with mild cog-
MoCA scores from the first to second evaluation was nitive impairment (MCI) and Alzheimers disease (AD).
698 NASREDDINE ET AL. APRIL 2005VOL. 53, NO. 4 JAGS

the MoCA. The correlation between the MoCA and the forms. Content validity was established via a close corre-
MMSE was high (r (274) 5 0.87, Po.001). lation between MoCA and MMSE scores.
Sensitivity and specificity were determined using clin- The specificity of the MoCA to exclude elderly normal
ical diagnosis as the standard for patients and controls. A controls was good (87%), although slightly lower than the
cutoff of 26 (scores of 25 or below indicate impairment) MMSE. More important, the MoCAs sensitivity in detect-
yielded the best balance between sensitivity and specificity ing MCI was excellent (90%), and it was considerably more
for the MCI and AD groups. A cutoff score of 26 was also sensitive than was the MMSE. The MoCA also detected
used for the MMSE for comparison purposes, because there mild AD with high sensitivity (100%) and excellent
was no optimal single score, and it has been demonstrated specificity (87%). Results were comparable in two sepa-
that no single cutoff score serves all purposes.6 rate institutions, indicating that it is useful in an academic
Sensitivity was calculated separately for the MCI and setting (JGH) and a community setting (NRS memory clin-
AD groups. The MoCA exhibited excellent sensitivity in ic). Although the AD participants were older and less well
identifying MCI and AD (90% and 100%, respectively). In educated than the MCI and NC participants, the critical
contrast, the sensitivity of the MMSE was poor (18% and MCI and NC groups were equivalent to each other in terms
78%, respectively). Specificity was defined as the percent- of age and education.
age of NCs that scored at or above the cutoff score of 26. There are several features in MoCAs design that likely
The MMSE had excellent specificity, correctly identifying explain its superior sensitivity for detecting MCI. The
100% of the NCs. The MOCA had very good to excellent MoCAs memory testing involves more words, fewer learn-
specificity (87%). Moreover, positive and negative predic- ing trials, and a longer delay before recall than the MMSE.
tive values for the MoCA were excellent for MCI (89% and Executive functions, higher-level language abilities, and
91%, respectively) and AD (89% and 100%, respectively). complex visuospatial processing can also be mildly im-
paired in MCI participants and are assessed by the
Participants MMSE and MoCA Scores Distribution MoCA with more numerous and demanding tasks than
As demonstrated by the standard deviation bars in Figure 1 the MMSE.
and the scatterplot distribution of scores in Figure 2, the When considering MMSE and MoCA performance in
MMSE scores of NCs had considerable distributional over- the same participants (Figure 2), an important pattern
lap with the MCI participants and, to some degree, with emerged. The majority of NC participants scored in the
mild AD patients. In fact, the majority of MCI participants normal range, and the majority of AD patients scored in
and some mild AD participants had MMSE scores in the the abnormal range on both tests, but three-quarters of
normal range. In contrast, few MCI participants and no AD the MCI participants scored in the abnormal range on the
participants scored in the normal range on the MoCA. MoCA but were considered normal according to the
When MMSE and MoCA scores were plotted together MMSE. In clinical practice, patients screened and found
(Figure 2), a striking pattern emerged. The large majority of to have a MoCA score over 26 would be extremely unlikely
NC participants scored in the normal range, and the large to meet clinical and neuropsychological criteria for
majority of AD patients scored in the abnormal range on MCI even after extensive evaluation. In general practice
both MMSE and MoCA. In contrast, 73% of MCI partic- therefore, using the MoCA as a screening tool should
ipants scored in the abnormal range on the MoCA but in the provide quick guidance for referral and further investiga-
normal range on the MMSE. tion of MCI.
The following presents a practical approach to evalu-
DISCUSSION ating patients presenting with cognitive complaints. Pa-
tients who present with cognitive complaints and functional
The MoCA demonstrated high test-retest reliability, good
impairment are most likely to suffer from dementia. The
internal consistency, and equivalence in its two language
MMSE could be administered first because it is likely to be
MoCA and MMSE Scatter abnormal (78% of those with mild AD had an abnormal
MMSE score). If the MMSE is normal (
26), the MoCA
30 should then be administered (100% of those with mild AD
had an abnormal MoCA score). In contrast, patients who
present with cognitive complaints but no functional im-
25
pairment are likely to be normal or have MCI. In these
MMSE

patients, one should administer the MoCA first because the

20 MMSE will most likely produce a normal score in either
case. The MoCA is highly acceptable to the MCI popula-
tion, many of whom find the MMSEs cognitive tasks in-
15 sultingly simple. This approach improves efficiency in
5 10 15 20 25 30 evaluating patients with cognitive complaints. Separating
MoCA patients with MCI from those with AD will still rely on
NC MCI AD clinical judgment, particularly in assessing whether the pa-
tient has functional impairment. Both groups will usually
Figure 2. Scatter plot of Montreal Cognitive Assessment have abnormal MoCA scores.
(MoCA) and Mini-Mental State Examination (MMSE) scores There are no screening tools that can quickly assess
for normal controls (NCs) and subjects with mild cognitive im- very different levels of cognitive impairment. The MoCA is
pairment (MCI) and Alzheimers disease (AD). useful for the mild stages of the cognitive impairment spec-
JAGS APRIL 2005VOL. 53, NO. 4 MOCA: A BRIEF SCREENING TOOL FOR MCI 699

trum (including MCI and mild AD), and the MMSE is Special thanks to Luce Hebert, RN, for her dedication in
superior for more-advanced stages (AD patients with more- collecting clinical data.
significant functional impairment).
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