![]() Our research purpose differed from prior reports comparing the MoCA to the MMSE in that we wished to establish a MoCA score range that captures as many MCI cases as reasonable, including those at a very early stage, as designated using ADNI study criteria. These early MCI cases often perform in the normal range on routine office-based tests, such as the MoCA and MMSE, whereas late MCI cases can score in the mild dementia range. ![]() Accordingly, the Alzheimer’s Disease Neuroimaging Initiative (ADNI) study has extended the range of their designation of MCI cases beyond the Peterson criteria to include those at earlier stages. ![]() Because functional impairment is required for a dementia diagnosis, this could be a differentiating feature from MCI when cognitive scores overlap. More sensitive neuropsychological tests would need to be applied secondarily to separate those with cognitive complaints representing the earliest MCI cases from HCs. Further, for clinicians wishing to detect cognitive impairment earlier, knowing the MCI score range using an office-based test like the MoCA would be very helpful. As MCI becomes a more commonly targeted population for clinical trials, the ability to capture the full range of MCI cases is crucial. Also, MCI and dementia often comprised a cognitively impaired group where identifying cutoff values from HCs were sought. Thus, current MoCA literature has focused on MCI defined more consistent with what is now considered late MCI. These investigators and others who have evaluated lower MoCA cutoff values of ≤23 and ≤20 report increased detection of impaired MCI cases from HCs but risk leaving more subtly impaired MCI cases within the normal range. found that an MMSE cutoff ≤24 did not distinguish HCs from MCI however, the MoCA, using a cutoff of ≤23, with 96 % sensitivity and 95 % specificity, did. Using the Peterson criteria for amnestic MCI, Luis et al. Subsequent studies explored lower MoCA cutoff scores to increase specificity for detection of cognitive impairment as compared to HCs. The MoCA had greater sensitivity than MMSE in detecting MCI versus HCs (90 % versus 18 %) however, specificity was lower for the MoCA than MMSE (87 % versus 100 %). MoCA scores for MCI subjects were detected as abnormal in 73 % of those whose MMSE was normal. Mean scores in HC, MCI and mild AD dementia groups were lower on the MoCA than MMSE, though the overall correlation between tests was high ( r = 0.87). The initial MoCA validation study required an MMSE score of at least 17 for inclusion and used cutoff values of ≤25 on both tests to denote abnormal scores consistent with amnestic MCI (Peterson criteria) or mild AD. found a higher correlation of the MoCA than MMSE with neuropsychological tests for memory, executive functioning, visuospatial, and the Mattis Dementia Rating Scale. reported better longitudinal sensitivity for MoCA than MMSE. ![]() Greater sensitivity to detect mild levels of cognitive impairment has been reported for the MoCA in MCI and AD dementia, stroke and transient ischemic attack patients and Parkinson’s disease. Though it offers many of the same advantages of the MMSE, the MoCA was developed as a more challenging test that includes executive function, higher-level language, and complex visuospatial processing to enable detection of mild impairment with less ceiling effect. As research increasingly focuses on milder stages of AD, options other than the MMSE are needed for clinicians for earlier diagnosis and management. Its poor sensitivity for distinguishing mild cognitive impairment (MCI) is well-described and can be attributed to a lack of complexity as well as the absence of executive function items. One problem with the MMSE is its ceiling effect or limited dynamic performance range for normal individuals, which increases the likelihood that persons in predementia stages score within the normal range (24 and above). The MMSE is also commonly used as a proxy for staging of Alzheimer’s disease (AD). Though there are a number of possible tests, they recommend the Mini-Mental State Examination (MMSE), the most widely used cognitive screening test used by physicians for general cognitive evaluation, and also the newer Montreal Cognitive Assessment (MoCA). Galvin and Sadowski recently wrote clinical recommendations for primary care physician evaluation of older patients for cognitive impairment, emphasizing the need to look for early warning signs where formal cognitive testing can aid detection. Office-based, multi-domain cognitive tests are commonly administered in clinical situations to evaluate patients with cognitive impairment. ![]()
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