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1.  Screening for Very Mild Subcortical Vascular Dementia Patients Aged 75 and Above Using the Montreal Cognitive Assessment and Mini-Mental State Examination in a Community: The Kurihara Project 
Aims
To examine the effectiveness of the Montreal Cognitive Assessment (MoCA) to screen people with mild cognitive impairment (MCI), to associate the MoCA score with the presence of infarction, and to detect the characteristics of people with very mild subcortical vascular dementia (vmSVD).
Methods
392 out of 886 community dwellers aged 75 years and above living in Kurihara, Northern Japan, agreed to participate in our study; 164 scored a Clinical Dementia Rating (CDR) of 0 (healthy), 184 scored a CDR of 0.5 (MCI) and 44 scored a CDR of 1+ (dementia). The participants scoring a CDR of 0.5 were divided into 2 subtypes: 37 had vmSVD and 147 had other types of dementia. The objective variables were the total MoCA, the MoCA subscale and the Mini-Mental State Examination (MMSE).
Results
There was a difference in the MoCA and MMSE scores between the 3 CDR groups. The MoCA score overlapped in participants with CDR 0 and 0.5. There were significant CDR effects, while there were no significant infarction effects for the MoCA and MMSE. vmSVD participants had lower scores on the total MoCA, the MoCA attention subscale and MMSE than healthy elderly people and participants with other types of dementia.
Conclusion
Our results suggested that MMSE performed rather well and that the MoCA is not superior to MMSE in MCI and vmSVD participants aged 75 and above in a community.
doi:10.1159/000340047
PMCID: PMC3522454  PMID: 23277783
Montreal Cognitive Assessment; Clinical Dementia Rating; Mild cognitive impairment; Subcortical vascular dementia; Community
2.  The Beijing version of the montreal cognitive assessment as a brief screening tool for mild cognitive impairment: a community-based study 
BMC Psychiatry  2012;12:156.
Background
A cross-sectional validation study was conducted in several urban and rural communities in Beijing, China, to evaluate the effectiveness of the Beijing version of the Montreal Cognitive Assessment (MoCA-BJ) as a screening tool to detect mild cognitive impairment (MCI) among Chinese older adults.
Methods
The MoCA-BJ and the Mini-Mental State Examination (MMSE) were administered to 1001 Chinese elderly community dwellers recruited from three different regions (i.e., newly developed, old down-town, and rural areas) in Beijing. Twenty-one of these participants were diagnosed by experienced psychiatrists as having dementia, 115 participants were diagnosed as MCI, and 865 participants were considered to be cognitively normal. To analyze the effectiveness of the MoCA-BJ, we examined its psychometric properties, conducted item analyses, evaluated the sensitivity and specificity of the scale, and compared the scale with the MMSE. Demographic and regional differences among our subjects were also taken into consideration.
Results
Under the recommended cut-off score of 26, the MoCA-BJ demonstrated an excellent sensitivity of 90.4%, and a fair specificity (31.3%). The MoCA-BJ showed optimal sensitivity (68.7%) and specificity (63.9%) when the cut-off score was lowered to 22. Among all the seven cognitive sub-domains, delayed recall was shown to be the best index to differentiate MCI from the normal controls. Regional differences disappeared when the confounding demographic variables (i.e., age and education) were controlled. Item analysis showed that the internal consistency was relatively low in both naming and sentence repetition tasks, and the diagnostic accuracy was similar between the MoCA-BJ and the MMSE.
Conclusions
In general, the MoCA-BJ is an acceptable tool for MCI screening in both urban and rural regions of Beijing. However, presumably due to the linguistic and cultural differences between the original English version and the Chinese version of the scale, and the lower education level of Chinese older adults, the MoCA-BJ is not much better than the MMSE in detecting MCI, at least for this study sample. Further modifications to several test items of the MoCA-BJ are recommended in order to improve the applicability and effectiveness of the MoCA-BJ in MCI screening among the Chinese population.
doi:10.1186/1471-244X-12-156
PMCID: PMC3499377  PMID: 23009126
MoCA-BJ; MMSE; Mild cognitive impairment; Dementia; Cognitive assessment
3.  Montreal Cognitive Assessment Performance in Patients with Parkinson’s Disease with “Normal” Global Cognition According to Mini-Mental State Examination Score 
OBJECTIVES
To examine Montreal Cognitive Assessment (MoCA) performance in patients with Parkinson’s disease (PD) with “normal” global cognition according to Mini-Mental State Examination (MMSE) score.
DESIGN
A cross-sectional comparison of the MoCA and the MMSE.
SETTING
Two movement disorders centers at the University of Pennsylvania and the Philadelphia Veterans Affairs Medical Center.
PARTICIPANTS
A convenience sample of 131 patients with idiopathic PD who were screened for cognitive and psychiatric complications.
MEASUREMENTS
Subjects were administered the MoCA and MMSE, and only subjects defined as having a normal age- and education-adjusted MMSE score were included in the analyses (N = 100). As previously recommended in patients without PD, a MoCA score less than 26 was used to indicate the presence of at least mild cognitive impairment (MCI).
RESULTS
Mean MMSE and MoCA scores ± standard deviation were 28.8 ± 1.1 and 24.9 ± 3.1, respectively. More than half (52.0%) of subjects with normal MMSE scores had cognitive impairment according to their MoCA score. Impairments were seen in numerous cognitive domains, including memory, visuospatial and executive abilities, attention, and language. Predictors of cognitive impairment on the MoCA using univariate analyses were male sex, older age, lower educational level, and greater disease severity; older age was the only predictor in a multivariate model.
CONCLUSION
Approximately half of patients with PD with a normal MMSE score have cognitive impairment based on the recommended MoCA cutoff score. These results suggest that MCI is common in PD and that the MoCA is a more sensitive instrument than the MMSE for its detection.
doi:10.1111/j.1532-5415.2008.02096.x
PMCID: PMC2754699  PMID: 19170786
cognitive impairment; Parkinson’s disease; Mini-Mental State Examination; Montreal Cognitive Assessment; neuropsychology
4.  Cognitive Performance on the Mini-Mental State Examination and the Montreal Cognitive Assessment Across the Healthy Adult Lifespan 
Objective
We sought to compare age-related performance on the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) across the adult lifespan in an asymptomatic, presumably normal, sample.
Background
The MMSE is the most commonly used brief cognitive screening test; however, the MoCA may be better at detecting early cognitive dysfunction.
Methods
We gave the MMSE and MoCA to 254 community-dwelling participants ranging in age from 20 to 89, stratified by decade and we compared their scores using the Wilcoxon signed rank test.
Results
For the total sample, the MMSE and MoCA differed significantly in total scores as well as in visuospatial, language, and memory domains (for all of these scores, P <0.001). Mean MMSE scores declined only modestly across the decades; mean MoCA scores declined more dramatically. There were no consistent domain differences between the MMSE and MoCA during the 3rd and 4th decades; however, significant differences in memory (P <0.05) and language (P <0.001) emerged in the 5th through 9th decades.
Conclusions
We conclude that the MoCA may be a better detector of age-related decrements in cognitive performance than the MMSE, as shown in this community-dwelling adult population.
doi:10.1097/WNN.0b013e31828b7d26
PMCID: PMC3638088  PMID: 23538566
Mini-Mental State Examination (MMSE); Montreal Cognitive Assessment (MoCA); cognitive decline; healthy sample
5.  The Influence of Education on Chinese Version of Montreal Cognitive Assessment in Detecting Amnesic Mild Cognitive Impairment among Older People in a Beijing Rural Community 
The Scientific World Journal  2014;2014:689456.
To assess the influence of education on the performance of Chinese version of Montreal cognitive assessment (C-MoCA) in relation to the mini-mental state examination (MMSE) in detecting amnesic mild cognitive impairment (aMCI) among rural-dwelling older people C-MoCA and MMSE was administered and diagnostic interviews were conducted among community-dwelling elderly in two villages in Beijing. The performance of C-MoCA and MMSE in detecting aMCI was evaluated by the area under the ROC curve (AUC). Effect size of education on variations in C-MoCA scores was estimated with general linear model. Among 172 study participants (24 cases of aMCI and 148 normal controls), the AUC of C-MoCA was 0.72 (95% CI = 0.62–0.81, cutoff = 20/21), compared to AUC of MMSE of 0.74 (95% CI = 0.64–0.84, cutoff = 26/27). The performance of both C-MoCA and MMSE was especially poorer among those with low (0–6 years) education. After controlling for gender and age, education (η2 = 0.204) had a surpassing effect over aMCI diagnosis (η2 = 0.052) on variations in C-MoCA scores. Among rural older people, the MoCA showed modest accuracy and was no better than MMSE in detecting aMCI, especially in those with low education, due to the overwhelming effect of education relative to aMCI diagnosis on variations in C-MoCA performance.
doi:10.1155/2014/689456
PMCID: PMC4058117  PMID: 24982978
6.  The Montreal Cognitive Assessment (MoCA) - A Sensitive Screening Instrument for Detecting Cognitive Impairment in Chronic Hemodialysis Patients 
PLoS ONE  2014;9(10):e106700.
Background
Chronic kidney disease (CKD) patients undergoing hemodialysis (HD) therapy have an increased risk of developing cognitive impairment and dementia, which are known relevant factors in disease prognosis and therapeutic success, but still lack adequate screening in clinical routine. We evaluated the Montreal Cognitive Assessment (MoCA) for suitability in assessing cognitive performance in HD patients in comparison to the commonly used Mini-Mental State Examination (MMSE) and a detailed neuropsychological test battery, used as gold standard.
Methods
43 HD patients and 42 healthy controls with an average age of 58 years, were assessed with the MoCA, the MMSE and a detailed neuropsychological test battery, covering the domains of memory, attention, language, visuospatial and executive functions. Composite scores were created for comparison of cognitive domains and test results were analyzed using Spearman's correlation and linear regression. Cognitive dysfunction was defined using z-score values and predictive values were calculated. Sensitivity and specificity of the MoCA were determined using receiver operating characteristic (ROC) analysis.
Results
HD patients performed worse in all cognitive domains, especially in memory recall and executive functions. The MoCA correlated well with the detailed test battery and identified patients with cognitive impairment with a sensitivity of 76.7% and specificity of 78.6% for a cut-off value of ≤24 out of 30 points. In the detailed assessment executive functions accounted significantly for performance in the MoCA. The MMSE only discriminated weakly between groups.
Conclusions
The MoCA represents a suitable cognitive screening tool for hemodialysis patients, demonstrating good sensitivity and specificity levels, and covering executive functions, which appear to play an important role in cognitive performance of HD patients.
doi:10.1371/journal.pone.0106700
PMCID: PMC4209968  PMID: 25347578
7.  Glucose Metabolism Measured by Positron Emission Tomography is Reduced in Patients with White Matter Presumably Ischemic Lesions 
Background
The severity and progression of white matter ischemic lesion (WMIL) are closely linked to vascular dementia. The function of neural tissue is closely linked to glucose consumption as the most important energy-supplying metabolic process. At present, 18fluorine-fluorodeoxy glucose (18FDG) positron emission tomography (PET) can provide regional and 3-dimensional quantification of glucose metabolism in the human brain. Although MMSE and MoCA are commonly used screens in cognitive impairment, no research team has yet validated their performance in WMIL. The purpose of our study was to compare MMSE and MoCA in screening for cognitive impairment and to explore the correlations between CMRglu values and executive function.
Material/Methods
All the participants underwent comprehensive clinical, MoCA, MMSE, MRI, and PET examinations. Patients in the WMIL group were subdivided into 3 severity subgroups according to the Fazekas scale.
Results
The MoCA scores were lower in the WMIL group. Our research indicates that MoCA is a more sensitive screening tool than the commonly used MMSE in detecting cognitive impairment in patients with WMIL. CMRglu values of gray matter were decreased in the WMIL group. Reductions of CMRglu in parietal lobe, frontal lobe, and white matter centrum semiovale were observed to different degrees in the WMIL groups according to the modified Fazekas scale. A significant negative correlation was found between executive function and CMRglu in the frontal lobe.
Conclusions
MoCA appears to be a more sensitive screening tool than the commonly used MMSE in detecting cognitive impairment in patients with WMIL. CMRglu can potentially be used as a biomarker for predicting the severity of WMIL.
doi:10.12659/MSM.892137
PMCID: PMC4156339  PMID: 25159539
Leukoaraiosis; Mild Cognitive Impairment; Positron-Emission Tomography
8.  Cognitive screening improves the predictive value of stroke severity scores for functional outcome 3–6 months after mild stroke and transient ischaemic attack: an observational study 
BMJ Open  2013;3(9):e003105.
Objectives
To investigate the prognostic value of the neurocognitive status measured by screening instruments, the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE), individually and in combination with the stroke severity scale, the National Institute of Health Stroke Scale (NIHSS), obtained at the subacute stroke phase or the baseline (≤2 weeks), for functional outcome 3–6 months later.
Design
Prospective observational study.
Setting
Tertiary stroke neurology service.
Participants
400 patients with a recent ischaemic stroke or transient ischaemic attack (TIA) received NIHSS, MoCA and MMSE at baseline and were followed up 3–6 months later.
Primary outcome measures
At 3–6 months following the index event, functional outcome was measured by the modified Rankin Scale (mRS) scores.
Results
Most patients (79.8%) had a mild ischaemic stroke and less disability (median NIHSS=2, median mRS=2 and median premorbid mRS=0), while a minority of patients had TIA (20.3%). Baseline NIHSS, MMSE and MoCA scores individually predicted mRS scores at 3–6 months, with NIHSS being the strongest predictor (NIHSS: R2 change=0.043, p<0.001). Moreover, baseline MMSE scores had a small but statistically significant incremental predictive value to the baseline NIHSS for mRS scores at 3–6 months, while baseline MoCA scores did not (MMSE: R2 changes=0.006, p=0.03; MoCA: R2 changes=0.004, p=0.083). However, in patients with more severe stroke at baseline (defined as NIHSS>2), baseline MoCA and MMSE had a significant and moderately large incremental predictive value to the baseline NIHSS for mRS scores at 3–6 months (MMSE: R2 changes=0.021, p=0.010; MoCA: R2 changes=0.017, p=0.021).
Conclusions
Cognitive screening at the subacute stroke phase can predict functional outcome independently and improve the predictive value of stroke severity scores for functional outcome 3–6 months later, particularly in patients with more severe stroke.
doi:10.1136/bmjopen-2013-003105
PMCID: PMC3773644  PMID: 24002980
GERIATRIC MEDICINE; REHABILITATION MEDICINE
9.  Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease 
Neurology  2009;73(21):1738-1745.
Background:
Due to the high prevalence of mild cognitive impairment (MCI) and dementia in Parkinson disease (PD), routine cognitive screening is important for the optimal management of patients with PD. The Montreal Cognitive Assessment (MoCA) is more sensitive than the commonly used Mini-Mental State Examination (MMSE) in detecting MCI and dementia in patients without PD, but its validity in PD has not been established.
Methods:
A representative sample of 132 patients with PD at 2 movement disorders centers was administered the MoCA, MMSE, and a neuropsychological battery with operationalized criteria for deficits. MCI and PD dementia (PDD) criteria were applied by an investigator blinded to the MoCA and MMSE results. The discriminant validity of the MoCA and MMSE as screening and diagnostic instruments was ascertained.
Results:
Approximately one third of the sample met diagnostic criteria for a cognitive disorder (12.9% PDD and 17.4% MCI). Mean (SD) MoCA and MMSE scores were 25.0 (3.8) and 28.1 (2.0). The overall discriminant validity for detection of any cognitive disorder was similar for the MoCA and the MMSE (receiver operating characteristic area under the curve [95% confidence interval]): MoCA (0.79 [0.72, 0.87]) and MMSE (0.76 [0.67, 0.85]), but as a screening instrument the MoCA (optimal cutoff point = 26/27, 64% correctly diagnosed, lack of ceiling effect) was superior to the MMSE (optimal cutoff point = 29/30, 54% correctly diagnosed, presence of ceiling effect).
Conclusions:
The Montreal Cognitive Assessment, but not the Mini-Mental State Examination, has adequate psychometric properties as a screening instrument for the detection of mild cognitive impairment or dementia in Parkinson disease. However, a positive screen using either instrument requires additional assessment due to suboptimal specificity at the recommended screening cutoff point.
GLOSSARY
= Alzheimer disease;
= area under the curve;
= deep brain stimulation;
= Diagnostic and Statistical Manual of Mental Disorders, 4th edition;
= Geriatric Depression Scale;
= Hopkins Verbal Learning Test;
= instrumental activities of daily living;
= mild cognitive impairment;
= Mini-Mental State Examination;
= Montreal Cognitive Assessment;
= negative predictive value;
= Parkinson disease;
= Parkinson disease dementia;
= positive predictive value;
= quality of life;
= receiver operating characteristic;
= Tower of London-Drexel;
= Unified Parkinson’s Disease Rating Scale.
doi:10.1212/WNL.0b013e3181c34b47
PMCID: PMC2788810  PMID: 19933974
10.  Comparative accuracies of two common screening instruments for the classification of Alzheimer’s disease, mild cognitive impairment and healthy aging 
Objective
To compare the utility and diagnostic accuracy of the MoCA and MMSE in the diagnosis of Alzheimer’s disease (AD) and Mild Cognitive Impairment (MCI) in a clinical cohort.
Method
321 AD, 126 MCI and 140 older adults with healthy cognition (HC) were evaluated using the the MMSE, MoCA, a standardized neuropsychological battery according to the Consortium to Establish a Registry of Alzheimer’s Disease (CERAD-NB) and an informant based measure of functional impairment, the Dementia Severity Rating Scale (DSRS). Diagnostic accuracy and optimal cut-off scores were calculated for each measure, and a method for converting MoCA to MMSE scores is presented also.
Results
The MMSE and MoCA offer reasonably good diagnostic and classification accuracy as compared to the more detailed CERAD-NB; however, as a brief cognitive screening measure the MoCA was more sensitive and had higher classification accuracy for differentiating MCI from HC. Complementing the MMSE or the MoCA with the DSRS significantly improved diagnostic accuracy.
Conclusion
The current results support recent data indicating that the MoCA is superior to the MMSE as a global assessment tool, particularly in discerning earlier stages of cognitive decline. In addition, we found that overall diagnostic accuracy improves when the MMSE or MoCA is combined with an informant-based functional measure. Finally, we provide a reliable and easy conversion of MoCA to MMSE scores. However, the need for MCI-specific measures is still needed to increase the diagnostic specificity between AD and MCI.
doi:10.1016/j.jalz.2012.10.001
PMCID: PMC4036230  PMID: 23260866
Alzheimer’s disease; Mild Cognitive Impairment; MMSE; MoCA; Diagnostic accuracy
11.  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.
Objective
Cognitive deficits are common after aneurysmal subarachnoid haemorrhage (aSAH), and clinical evaluation is important for their management. Our hypothesis was that the Montreal Cognitive Assessment (MoCa) is superior to the Mini-Mental State Examination (MMSE) in screening for cognitive domain deficit in aSAH patients.
Methods
We carried out a prospective observational and diagnostic accuracy study on Hong Kong aSAH patients aged 21 to 75 years who had been admitted within 96 hours of ictus. The domain-specific neuropsychological assessment battery, the MoCA and MMSE were administered 2–4 weeks and 1 year after ictus. A cognitive domain deficit was defined as a cognitive domain z score <−1.65 (below the fifth percentile). Cognitive impairment was defined as two or more cognitive domain deficits. The study is registered at ClinicalTrials.gov of the US National Institutes of Health (NCT01038193).
Results
Both the MoCA and the MMSE were successful in differentiating between patients with and without cognitive domain deficits and cognitive impairment at both assessment periods. At 1 year post-ictus, the MoCA produced higher area under the curve scores for cognitive impairment than the MMSE (MoCA, 0.92; 95% CI, 0.83 to 0.97 versus MMSE, 0.77; 95% CI, 0.66 to 0.83, p = 0.009).
Interpretation
Cognitive domain deficits and cognitive impairment in patients with aSAH can be screened with the MoCA in both the subacute and chronic phases.
doi:10.1371/journal.pone.0059946
PMCID: PMC3616097  PMID: 23573223
12.  Using the Montreal Cognitive Assessment Scale to screen for dementia in Chinese patients with Parkinson's Disease 
Shanghai Archives of Psychiatry  2013;25(5):306-313.
Background
Dementia is one of the most distressing and burdensome health problems associated with Parkinson's Disease (PD). The Montreal Cognitive Assessment scale (MoCA) is widely used to screen for dementia in PD patients, but the appropriate diagnostic cutoff score when used with Chinese PD patients is not known.
Aim
Determine a diagnostic cutoff value of the Chinese version of the MoCA (MoCA-C) for Chinese PD patients and describe the characteristics of PD patients screened positive for dementia using the MoCA-C.
Methods
The presence of dementia in 616 PD patients and 85 community controls was determined using the Movement Disorder Society Task Force criteria (the gold standard diagnosis). We administered the MoCA-C to these individuals and used a receiver operating characteristic (ROC) curve to identify the cutoff score of the MoCA-C that most efficiently identified dementia in both PD patients and community controls. Demographic and clinical characteristics of PD patients who were screened positive or negative for dementia using the MoCA-C were compared.
Results
A MoCA-C score of 23 was the optimal cutoff score for dementia in both patients and controls. Using this cutoff score, the sensitivity and specificity of the MoCA-C in PD patients were 0.70 and 0.77, respectively; the positive and negative predictive values were 0.59 and 0.85, respectively; and the overall concordance (kappa [95% confidence interval]) was 0.45 (0.39-0.52). The corresponding kappa value (concordance) in community controls was only 0.25 (0.05-0.45). Compared to PD patients who screened negative for dementia, those who screened positive for dementia were significantly impaired in all cognitive domains, including visuospatial and executive functioning, naming, attention, language, abstraction, delayed recall and orientation (all p<0.001). Among the PD patients, screening positive for dementia was independently associated with old age, low educational attainment, female gender and more severe motor impairment.
Conclusions
The commonly recommended cutoff screening score for dementia of 26 on the MoCA it too high for PD patients in China; a cutoff score of 23 is more appropriate. Potential risk factors for dementia in Chinese PD patients include older age, less education, and more severe motor symptoms of PD.
doi:10.3969/j.issn.1002-0829
PMCID: PMC4054575  PMID: 24991170
13.  Relationship between cognitive impairment and apparent diffusion coefficient values from magnetic resonance-diffusion weighted imaging in elderly hypertensive patients 
Background
The purpose of this study was to determine a new method for the early diagnosis and assessment of mild cognitive impairment in elderly individuals with hypertension. Elderly hypertensive patients with cognitive impairment were assessed by the Montreal Cognitive Assessment (MoCA) and Clinical Dementia Rating Assessment (CDR). Cognitive results were compared to apparent diffusion coefficient (ADC) values from magnetic resonance-diffusion weighted imaging.
Methods
A total of 191 patients were categorized into four groups: a control group (normal cognition and no hypertension; n=20); a normal group (hypertension and normal cognition; n=33); an mild cognitive impairment group (n=80); and a vascular dementia group (n=58). The MoCA and CDR tests were used to determine cognition. ADC values in eight brain regions were calculated with magnetic resonance-diffusion weighted imaging. Other characteristics were evaluated, eg, blood pressure, MoCA, and CDR scores, and the comparisons of the four groups were made.
Results
The MoCA and CDR scores differed among the four groups (P<0.001). Systolic and diastolic blood pressure values increased as cognitive function declined (P<0.001). Cognitive function declined as ADC values increased, and they differed between elderly people with and without hypertension (P<0.001). Among elderly hypertensive participants, ADC values were significantly increased in the cortex and hippocampus.
Conclusion
The MoCA and CDR tests were sufficiently sensitive to evaluate cognition. Blood pressure was closely related to cognition, as well as to functional and structural changes in the brain. These alterations were evidenced through changes in the ADC values and were most obvious in the cortex and hippocampus. Greater cognitive decline was observed in elderly participants with hypertension compared to those without. As hypertensive stage increased, greater ADC values were observed.
doi:10.2147/CIA.S63567
PMCID: PMC4122089  PMID: 25114516
Clinical Dementia Rating Assessment; hypertension; mild cognitive impairment; Montreal Cognitive Assessment
14.  Reliability, Validity, and Optimal Cutoff Score of the Montreal Cognitive Assessment (Changsha Version) in Ischemic Cerebrovascular Disease Patients of Hunan Province, China 
Background/Aims
The goal of this study was to examine the reliability and validity of the Changsha version of the Montreal Cognitive Assessment (MoCA-CS) in ischemic cerebrovascular disease patients of Hunan Province, China, and to explore the optimal cutoff score for detecting vascular cognitive impairment-no dementia (VCI-ND) and vascular dementia (VD).
Methods
Three hundred and thirty-eight ischemic cerebrovascular disease patients (131 with normal cognition, 111 with VCI-ND, and 96 with VD) and 132 healthy controls were recruited. All participants accepted examination by the MoCA-CS, Mini-Mental State Examination (MMSE), and other related scales. A detailed neuropsychological battery was used for making a final cognitive diagnosis. SPSS 16.0 statistical software was used for reliability, validity examination, and optimal cutoff score detection.
Results
Cronbach's α of the MoCA-CS was 0.884, and test-retest and interrater reliability of the MoCA-CS were 0.966 and 0.926, respectively. MoCA-CS scores were highly correlated with MMSE scores (r = 0.867) and simplified intelligence quotients (r = 0.822). The results indicate that 1 point should be added for subjects with less than 6 years of education, and that the optimal cutoff score for detecting VCI-ND is 26/27 (sensitivity 96.1%, specificity 75.6%), whereas the optimal cutoff score for detecting VD is 16/17 (sensitivity 92.7%, specificity 96.3%).
Conclusion
The MoCA-CS has good reliability and validity, and is a useful cognitive screening instrument for detecting VCI in the Chinese population.
doi:10.1159/000346845
PMCID: PMC3617974  PMID: 23637698
Neuropsychology; Psychometrics; Screening; Mild cognitive impairment and dementia; Vascular cognitive impairment; Vascular cognitive impairment-no dementia; Vascular dementia; Stroke
15.  Cognitive and neuropsychiatric impairment in cerebral radionecrosis patients after radiotherapy of nasopharyngeal carcinoma 
BMC Neurology  2014;14:10.
Background
We sought to characterize the cognitive function and neuropsychiatric symptoms in cerebral radionecrosis (CRN) patients who have received conformal radiation for nasopharyngeal carcinoma.
Methods
A total of 40 patients treated with radiotherapy (RT) that developed CRN (RT + CRN), 40 patients treated with radiotherapy that did not have CRN (RT-No-CRN), and 36 newly diagnosed untreated nasopharyngeal carcinoma patients (No-RT) were recruited. The cognitive function and neuropsychiatric symptoms were evaluated with Montreal cognitive assessment (MoCA), the mini-mental state examination (MMSE), activity of daily living scale (ADL), neuropsychiatric inventory (NPI), Hamilton depression scale (HAMD) and Hamilton anxiety scale (HAMA).
Results
The RT + CRN group had the lowest mean MMSE, MoCA and ADL scores, while highest mean NPI, HAMD and HAMA scores among the three patient groups (P < 0.05). Thirty (75%) of the RT + CRN patients were deemed cognitively impaired by the MoCA compared with 9 (22.5%) by the MMSE (χ 2  = 22.064; P < 0.001). Eighty-two percents of subject in RT + CRN group experienced neuropsychiatric symptoms within the past 4 weeks. Irritability, anxiety, depression and agitation in the RT + CRN group were of the most significantly frequent among the 3 groups.
Conclusions
The CRN patients generally have manifestations in cognitive and psychological impairment, which have their typical characteristics, and should be considered in CRN treatment and rehabilitation. The MoCA classifies more CRN patients as cognitively impaired than the MMSE, justifying further studies of the MoCA as an appropriate screen for CRN.
doi:10.1186/1471-2377-14-10
PMCID: PMC3897961  PMID: 24418214
Cerebral radionecrosis; Nasopharyngeal carcinoma; Cognitive impairment; Neuropsychiatric symptom
16.  Reliability and validity of the Repeatable Battery for the Assessment of Neuropsychological Status in community-dwelling elderly 
Introduction
The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is a widely used screening instrument in neuropsychological assessment and is a brief, individually administered measure. The present study aims to assess the reliability and validity of the Chinese version of the RBANS in community-dwelling elderly.
Material and methods
All subjects come from the community-dwelling elderly in Shanghai, China. They completed a questionnaire concerning demographic information, the mini-mental state examination (MMSE) and the Chinese version of the RBANS. To test for internal consistency, Cronbach's α was calculated for all six RBANS indices. Correlations between each of the RBANS and MMSE subtests were conducted to measure the concurrent validity. A confirmatory factor analysis (CFA) was conducted to test the construct validity.
Results
The final sample of participants included 236 community-dwelling elderly. The mean total score on the RBANS was 86.02 (±14.19). The RBANS total score showed strong internal consistency (r = 0.806), and the coefficient α value for each of the RBANS scales ranged from 0.142 to 0.727. The total RBANS score was highly correlated with that of the MMSE (r = 0.594, p<0.001), and the RBANS subtests also demonstrated strong correlations with most of the MMSE subtests. The results of the CFA indicated an acceptable fit between the Chinese version of the RBANS and the original.
Conclusions
The Chinese version of the RBANS had relatively good reliability and validity in a community-dwelling elderly sample. It may be a useful screening instrument for conducting cognitive assessments in community-dwelling elderly.
doi:10.5114/aoms.2011.25561
PMCID: PMC3258798  PMID: 22291831
Repeatable Battery for the Assessment of Neuropsychological Status; reliability; validity; neuropsychological assessment; the elderly
17.  Correlation of Sleep Disturbance and Cognitive Impairment in Patients with Parkinson’s Disease 
Journal of Movement Disorders  2014;7(1):13-18.
Objective
Cognitive impairment is a common nonmotor symptom of Parkinson’s disease (PD) and is associated with high mortality, caregiver distress, and nursing home placement. The risk factors for cognitive decline in PD patients include advanced age, longer disease duration, rapid eye movement sleep behavior disorder, hallucinations, excessive daytime sleepiness, and nontremor symptoms including bradykinesia, rigidity, postural instability, and gait disturbance. We conducted a cross-sectional study to determine which types of sleep disturbances are related to cognitive function in PD patients.
Methods
A total of 71 PD patients (29 males, mean age 66.46 ± 8.87 years) were recruited. All patients underwent the Mini- Mental State Examination (MMSE) and the Korean Version of the Montreal Cognitive Assessments (MoCA-K) to assess global cognitive function. Sleep disorders were evaluated with the Stanford Sleepiness Scale, Epworth Sleepiness Scale, Insomnia Severity Index (ISI), Pittsburg Sleep Quality Index, and Parkinson’s Disease Sleep Scale in Korea (PDSS).
Results
The ISI was correlated with the MMSE, and total PDSS scores were correlated with the MMSE and the MoCA-K. In each item of the PDSS, nocturnal restlessness, vivid dreams, hallucinations, and nocturnal motor symptoms were positively correlated with the MMSE, and nocturnal restlessness and vivid dreams were significantly related to the MoCA-K. Vivid dreams and nocturnal restlessness are considered the most powerful correlation factors with global cognitive function, because they commonly had significant correlation to cognition assessed with both the MMSE and the MoCA-K.
Conclusions
We found a correlation between global cognitive function and sleep disturbances, including vivid dreams and nocturnal restlessness, in PD patients.
doi:10.14802/jmd.14003
PMCID: PMC4051722  PMID: 24926405
Cognitive impairment; Parkinson’s disease; Sleep disturbance
18.  Predictors of cognitive impairment in an early stage Parkinson’s disease cohort 
Movement Disorders  2014;29(3):351-359.
The impact of Parkinson’s disease (PD) dementia is substantial and has major functional and socioeconomic consequences. Early prediction of future cognitive impairment would help target future interventions. The Montreal Cognitive Assessment (MoCA), the Mini-Mental State Examination (MMSE), and fluency tests were administered to 486 patients with PD within 3.5 years of diagnosis, and the results were compared with those from 141 controls correcting for age, sex, and educational years. Eighteen-month longitudinal assessments were performed in 155 patients with PD. The proportion of patients classified with normal cognition, mild cognitive impairment (MCI), and dementia varied considerably, depending on the MoCA and MMSE thresholds used. With the MoCA total score at screening threshold, 47.7%, 40.5%, and 11.7% of patients with PD were classified with normal cognition, MCI, and dementia, respectively; by comparison, 78.7% and 21.3% of controls had normal cognition and MCI, respectively. Cognitive impairment was predicted by lower education, increased age, male sex, and quantitative motor and non-motor (smell, depression, and anxiety) measures. Longitudinal data from 155 patients with PD over 18 months showed significant reductions in MoCA scores, but not in MMSE scores, with 21.3% of patients moving from normal cognition to MCI and 4.5% moving from MCI to dementia, although 13.5% moved from MCI to normal; however, none of the patients with dementia changed their classification. The MoCA may be more sensitive than the MMSE in detecting early baseline and longitudinal cognitive impairment in PD, because it identified 25.8% of those who experienced significant cognitive decline over 18 months. Cognitive decline was associated with worse motor and non-motor features, suggesting that this reflects a faster progressive phenotype.
doi:10.1002/mds.25748
PMCID: PMC4235340  PMID: 24395708
Parkinson’s disease; mild cognitive impairment; dementia; Mini-Mental State Examination; Montreal Cognitive Assessment
19.  Mesenchymal stem cells can modulate longitudinal changes in cortical thickness and its related cognitive decline in patients with multiple system atrophy 
Multiple system atrophy (MSA) is an adult-onset, sporadic neurodegenerative disease. Because the prognosis of MSA is fatal, neuroprotective or regenerative strategies may be invaluable in MSA treatment. Previously, we obtained clinical and imaging evidence that mesenchymal stem cell (MSC) treatment could have a neuroprotective role in MSA patients. In the present study, we evaluated the effects of MSC therapy on longitudinal changes in subcortical deep gray matter volumes and cortical thickness and their association with cognitive performance. Clinical and imaging data were obtained from our previous randomized trial of autologous MSC in MSA patients. During 1-year follow-up, we assessed longitudinal differences in automatic segmentation-based subcortical deep gray matter volumes and vertex-wise cortical thickness between placebo (n = 15) and MSC groups (n = 11). Next, we performed correlation analysis between the changes in cortical thickness and changes in the Korean version of the Montreal Cognitive Assessment (MoCA) scores and cognitive performance of each cognitive subdomain using a multiple, comparison correction. There were no significant differences in age at baseline, age at disease onset, gender ratio, disease duration, clinical severity, MoCA score, or education level between the groups. The automated subcortical volumetric analysis revealed that the changes in subcortical deep gray matter volumes of the caudate, putamen, and thalamus did not differ significantly between the groups. The areas of cortical thinning over time in the placebo group were more extensive, including the frontal, temporal, and parietal areas, whereas these areas in the MSC group were less extensive. Correlation analysis indicated that declines in MoCA scores and phonemic fluency during the follow-up period were significantly correlated with cortical thinning of the frontal and posterior temporal areas and anterior temporal areas in MSA patients, respectively. In contrast, no significant correlations were observed in the MSC group. These results suggest that MSC treatment in patients with MSA may modulate cortical thinning over time and related cognitive performance, inferring a future therapeutic candidate for cognitive disorders.
doi:10.3389/fnagi.2014.00118
PMCID: PMC4056280  PMID: 24982631
mesenchymal stem cells; multiple system atrophy; cortical thickness; cognition; clinical trial
20.  Proton magnetic resonance spectroscopy and cognitive impairment in patients with ischemic white matter lesions 
Background:
The purpose of this study is to investigate the relationship between the cognitive impairment and NAA/Cr and Cho/Cr ratios in the proton magnetic resonance spectroscopy (1HMRS), and to assess the importance of 1HMRS in the early diagnosis of cognitive impairment in patients with ischemic white matter lesions (WMLs).
Materials and Methods:
A total of 45 patients (23 males and 22 females) with the ischemic WML were divided into mild WML group (n = 15), moderate WML group (n = 15), and severe WML group (n = 15). A total of 15 healthy controls (8 males and 7 females) with no WML on magnetic resonance imaging were included. 1HMRS focusing on the frontal lobe white matter around the anterior horn of the lateral ventricle and Montreal Cognitive Assessment (MoCA) were conducted.
Results:
Patients with more severe WML had lower MoCA scores. The NAA/Cr ratio in 1HMRS was reduced in all the patients and was strongly correlated with the total MoCA scores (r = 0.845, P < 0.001). The Cho/Cr ratio in 1HMRS was increased in mild and moderate patients, was negatively correlated with the total MoCA scores (r = 0.907, P < 0.001). The Cho/Cr ratio was reduced in the severe patients and was positively correlated with the total MoCA scores (r = 0.937, P < 0.001). In addition, NAA/Cr and Cho/Cr ratios in 1HMRS were changed in patients with the mild WML whose total MoCA scores were similar to the controls.
Conclusion:
Our results suggest that NAA/Cr and Cho/Cr ratios in 1HMRS are useful indicators for early diagnosis of ischemic WML and cognitive impairment in patients with ischemic WML.
PMCID: PMC3908527  PMID: 24523797
1HMRS; Cho/Cr ratio; cognitive impairment; ischemic white matter; montreal cognitive assessment; NAA/Cr ratio; white matter lesions
21.  CORRELATION BETWEEN MOCA AND MMSE FOR THE ASSESSMENT OF COGNITION IN SCHIZOPHRENIA 
Acta Informatica Medica  2012;20(3):186-189.
Introduction:
Schizophrenia (Sch) is a complex neurodevelopmental disorder associated with impairment of cognitive function as a central feature, which is confirmed by a number of studies performed on patients suffering from Sch, where clinical symptoms and social functioning of patients are consequences of neurocognitive deficits.
Goal:
The goal of this study was to assess the clinical usability of the Montreal Cognitive Assessment (MoCA) as a screening instrument for cognitive impairment in schizophrenic patients, alone and in correlation with the Mini-Mental State Examination (MMSE).
Material and methods:
This clinical prospective study included 30 patients diagnosed with schizophrenia. Patients were selected from Psychiatric Clinic, Clinical Center University of Sarajevo (CCUS) during 2010. For assessment of cognitive impairment we used Montreal Cognitive Assessment Scale (MoCA) and Mini-Mental State Examination (MMSE).
Results:
From the total number of respondents (n=30), 15/30 (50 %) were males and 15/30 (50 %) were females; age of onset were 23.5±6.69; duration of illness before hospitalization (mean±SD) 32.5±12.9. If we make a comparison of MoCA scale and MMSE under the limit values, then we get that there was 10 true positive, 4 true negative, 14 false positive and 2 false negative. This all leads to sensitivity of MoCA scale again in comparison with the MMSE of 41.7%, specificity 66.7%, positive predictive value of 83.3% and negative predictive value of 22.2%.
Conclusions:
Our findings provide preliminary evidence that MoCA scale performs well in detecting true positive but it is imprecise in the detection of true negative findings.
doi:10.5455/aim.2012.20.186-189
PMCID: PMC3508854  PMID: 23322976
schizophrenia; cognitive deficit; MoCA; MMSE.
22.  Cognitive screening in the acute stroke setting 
Age and Ageing  2012;42(1):113-116.
Background: current literature suggests that two-thirds of patients will have cognitive impairment at 3 months post-stroke. Post-stroke cognitive impairment is associated with impaired function and increased mortality. UK guidelines recommend all patients with stroke have a cognitive assessment within 6 weeks. There is no ‘gold standard’ cognitive screening tool. The Montreal cognitive assessment (MoCA) is more sensitive than the Mini-Mental State Examination (MMSE) in mild cognitive impairment and for cognitive impairment in the non-acute post-stroke setting and in a Chinese-speaking acute stroke setting.
Methods: a convenience sample of 50 patients, admitted with stroke or transient ischaemic attack (TIA), were screened within 14 days, using the MoCA and the MMSE.
Results: the mean MoCA was 21.80 versus a mean MMSE of 26.98; 70% were impaired on the MoCA (cut-off <26) versus 26% on MMSE (cut-off <27). The MoCA could be completed in <10 min in 90% of cases.
Conclusion: the MoCA is easy and quick to use in the acute stroke setting. Further work is required to determine whether a low score on the MoCA in the acute stroke setting will predict the cognitive and functional status and to explore what the best cut-off should be in an acute post-stroke setting.
doi:10.1093/ageing/afs116
PMCID: PMC3518905  PMID: 22923608
stroke; cognitive impairment; post-stroke dementia; older people
23.  The Chinese (Cantonese) Montreal Cognitive Assessment in Patients with Subcortical Ischemic Vascular Dementia 
Background
Subcortical ischemic vascular dementia (SIVD) has been proposed as the most frequent subtype of vascular cognitive impairment. The aim of this study was to evaluate the psychometric properties of the Chinese (Cantonese) Montreal Cognitive Assessment (CC-MoCA) in patients with SIVD in the Guangdong Province of China.
Methods
71 SIVD patients and 60 matched controls were recruited for the CC-MoCA, Mini Mental State Examination and executive clock drawing tasks. Receiver-operating characteristic curve analyses were performed to determine optimal sensitivity and specificity of the CC-MoCA total score in differentiating mild vascular dementia (VaD) patients from moderate VaD patients and controls.
Results
The mean CC-MoCA scores of the controls, and mild and moderate VaD patients were 25.2 ± 3.8, 16.4 ± 3.7, and 10.0 ± 5.1, respectively. In our study, the optimal cutoff value for the CC-MoCA to be able to differentiate patients with mild VaD from controls is 21/22, and 13/14 to differentiate mild VaD from moderate VaD.
Conclusion
The CC-MoCA is a useful cognitive screening instrument in SIVD patients.
doi:10.1159/000331238
PMCID: PMC3235938  PMID: 22545038
Dementia; Cognitive impairments; Montreal Cognitive Assessment; Neuropsychology; Vascular dementia
24.  Abnormal Intrinsic Brain Activity Patterns in Patients with Subcortical Ischemic Vascular Dementia 
PLoS ONE  2014;9(2):e87880.
Objectives
To investigate the amplitude of low-frequency fluctuations (ALFF) alteration of whole brain in patients with subcortical ischemic vascular dementia (SIVD).
Materials and Methods
Thirty patients with SIVD and 35 control subjects were included in this study. All of them underwent structural MRI and rs-fMRI scan. The structural data were processed using the voxel-based morphometry 8 toolbox (VBM8). The rs-fMRI data were processed using Statistical Parametric Mapping (SPM8) and Data Processing Assistant for Resting-State fMRI (DPARSF) software. Within-group analysis was performed with a one-sample Student's t-test to identify brain regions with ALFF value larger than the mean. Intergroup analysis was performed with a two-sample Student's t-test to identify ALFF differences of whole brain between SIVD and control subjects. Partial correlations between ALFF values and Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) scores were analyzed in the SIVD group across the parameters of age, gender, years of education, and GM volume.
Results
Within-group analysis showed that the bilateral anterior cingulate cortex (ACC), posterior cingulate cortex, medial prefrontal cortex (MPFC), inferior parietal lobe (IPL), occipital lobe, and adjacent precuneus had significantly higher standardized ALFF values than the global mean ALFF value in both groups. Compared to the controls, patients with SIVD presented lower ALFF values in the bilateral precuneus and higher ALFF values in the bilateral ACC, left insula and hippocampus. Including GM volume as an extra covariate, the ALFF inter-group difference exhibited highly similar spatial patterns to those without GM volume correcting. Close negative correlations were found between the ALFF values of left insula and the MoCA and MMSE scores of SIVD patients.
Conclusion
SIVD is associated with a unique spontaneous aberrant activity of rs-fMRI signals, and measurement of ALFF in the precuneus, ACC, insula, and hippocampus may aid in the detection of SIVD.
doi:10.1371/journal.pone.0087880
PMCID: PMC3912127  PMID: 24498389
25.  Cognitive Impairment in Chronic Obstructive Pulmonary Disease 
PLoS ONE  2014;9(7):e102468.
Background/Purpose
Chronic obstructive pulmonary disease (COPD), especially in severe forms, is commonly associated with multiple cognitive problems. Montreal Cognitive Assessment test (MoCA) is used to detect cognitive impairment evaluating several areas: visuospatial, memory, attention and fluency. Our study aim was to evaluate the impact of stable COPD and exacerbation (AECOPD) phases on cognitive status using MoCA questionnaire.
Methods
We enrolled 39 patients (pts), smokers with COPD group D (30 stable and 9 in AECOPD) and 13 healthy subjects (control group), having similar level of education and no significant differences regarding the anthropometric measurements. We analyzed the differences in MoCA score between these three groups and also the correlation between this score and inflammatory markers.
Results
Patients with AECOPD had a significant (p<0.001) decreased MoCA score (14.6±3.4) compared to stable COPD (20.2±2.4) and controls (24.2±5.8). The differences between groups were more accentuated for the language abstraction and attention (p<0.001) and delayed recall and orientation (p<0.001) sub-topics. No significant variance of score was observed between groups regarding visuospatial and naming score (p = 0.095). The MoCA score was significantly correlated with forced expiratory volume (r = 0.28) and reverse correlated with C-reactive protein (CRP) (r = −0.57), fibrinogen (r = −0.58), erythrocyte sedimentation rate (ESR) (r = −0.55) and with the partial pressure of CO2 (r = −0.47).
Conclusions
According to this study, COPD significantly decreases the cognitive status in advanced and acute stages of the disease.
doi:10.1371/journal.pone.0102468
PMCID: PMC4102489  PMID: 25033379

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