The Montreal Cognitive Assessment (MoCA) is a popular screening tool used to detect signs of cognitive impairment. But despite the popularity of the MoCA test among 63.8% of medical experts, many physicians aren't comfortable making mild cognitive impairment (MCI) or dementia diagnoses. In fact, up to 40% of primary care providers (PCPs) report that they don't feel confident making a dementia diagnosis even though they're the earliest lines of support for patients. And when it comes to dementia, it’s early detection that creates the opportunity to improve patient outcomes.
There’s a gap in dementia detection, as screening tools like the MoCA aren't detailed enough for PCPs to make a confident diagnosis and in-depth neuropsychological exams can take months to schedule. The gap shows there's a need for tests that are sensitive enough to catch earlier signs of potential MCI, while being quick to deliver accurate results that support diagnosis before the disease progresses to later stages.
In this article, we discuss the strengths and limitations of the MoCA test and how it compares to newer computerized cognitive assessment tools. We show how computerized testing procedures have the potential to fill the gap in mild cognitive impairment detection, leading to more effective brain health treatments and better care for your patients.
What is the MoCA Test?
The MoCA is an 7 exercise cognitive test that takes approximately 10 minutes to complete. It uses a scoring method to measure a patient's cognitive health and check for signs of MCI. It was initially created in 2005 to improve upon the Mini-Mental State Examination (MMSE), which often fails to identify individuals with MCI. Traditionally, the MoCA has always been administered on pen and paper, but there are now versions available that can be accessed as a telehealth solution via the MoCA website or app.
Like all screening tests, the MoCA is considered a form of preventive care as it is designed to detect MCI if conducted as part of a regular healthcare check up. However, specialized testing via a neuropsychological exam is required to gather more detail or determine the source of a patient's cognitive difficulties—which may be due to Alzheimer's disease, Parkinson's disease, vascular dementia, and so on. Furthermore, the MoCA may have difficulty detecting milder declines in cognition before there is obvious subjective concern, which are hard to differentiate from the natural process of aging that older adults experience.
When is the MoCA Test Used?
The MoCA test can be implemented as soon as a patient expresses that they're experiencing cognitive dysfunction symptoms. Once the results are determined, a primary care provider can then refer the patient to a neurologist for further testing if required. The neurologist might administer the MoCA as well, using it as a screener to test cognitive function in a patient before their neuropsychological exam. When severe cognitive deficits are confirmed and potential causes identified, a cognitive care plan can be created to enhance their quality of life, monitor treatment efficacy and symptoms, and support their cognitive maintenance.
Typically, the MoCA screens for symptoms like memory loss, difficulty problem solving, and issues maintaining concentration, and severe disorientation. But by the time these symptoms are detected, it's often when the disease has already advanced to a severe stage, limiting the effectiveness of subsequent treatments.
What Do MoCA Test Scores Mean?
MoCA scores are derived from the interpretation of a patient's responses, with a maximum score of 30. The MoCA assesses seven cognitive domains, including:
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Executive function
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Visuospatial function
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Attention
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Language
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Abstraction
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Delayed recall
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Orientation
The patient's condition is assessed by calculating a total score across all of these areas. According to the MoCA website’s guidelines, if they have a total score of 26 or higher, then their cognitive health is considered normal. Scores of 19 to 25 can indicate MCI, while 10 to 18 can suggest moderate impairment. A score of less than 10 indicates severe impairment.
Unlike some other cognitive assessments, the MoCA requires the healthcare provider to complete a training and certification module. Only certified professionals have the training to interpret a patient's answers and assign appropriate scores to them. The downside is that this reduces the accessibility of the test, as not all PCPs have the time or inclination to complete the training. And even if they’re trained to interpret a patient's answers, there are multiple factors which can skew the results or lead to inaccurate interpretations.
How Reliable and Accurate is the MoCA for Detecting Dementia?
At the commonly recommended cutoff score of <26 for MCI, one review found that the MoCA has an estimated 93.7% sensitivity and 58.8% specificity. These accuracy results are higher than older assessments like the MMSE. However, patients scoring in this range may already have noticeable symptoms of MCI, rather than subtle signs of dementia’s earlier stages.
On the other hand, lower specificity means that many healthy people score in this range for reasons unrelated to cognitive decline, and they would not be identified as having MCI by more comprehensive testing.
Still, even with the MoCA’s higher accuracy rate, these limitations do raise the question:
Can Patients Pass the MoCA Test and Still Have Dementia?
It is possible that a patient can pass the MoCA test and still have mild cognitive impairment or dementia. The MoCA is just one tool used to assess cognitive function, and its sensitivity is not perfect. With its short length, simple exercises, and other limitations (see below), it is doubtful that it can pick up on every subtle sign of cognitive decline.
The opposite is also common: patients who are cognitively healthy—as verified by detailed neuropsychological testing—can still score below 26 on the MoCA. These false positives, though unavoidable in any cognitive test, can cause unnecessary uncertainty while waiting for more detailed testing to confirm or rule out genuine cognitive deficits.
For PCPs administering the MoCA test, including it within a broad range of assessments and ongoing cognitive health discussions is necessary to increase its effectiveness. A standalone test may not be enough to make a firm decision about a patient's condition.
Strengths and Limitations of the MoCA Test
Once a PCP knows the MoCA's pros and cons, they can then compare it with other assessments and make an informed decision on what's best for their practice, and their patients.
Strengths
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Ease of use: The MoCA only takes 10 minutes to administer and is available in pen-and-paper or computerized formats.
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Measures multiple areas of cognition: The test captures seven areas of cognition, including memory, attention, language, and visuospatial skills.
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High accuracy: It has a high chance to accurately screen a patient for cognitive dysfunction once they start displaying clear symptoms.
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Availability: The MoCA test is available in 35 different languages and has variations for people with blindness or impaired hearing.
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Copyright free: Unlike the MMSE, the MoCA is free for clinical use, though training and certification are considered mandatory.
Limitations
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Lack of detail: While the MoCA addresses 7 areas of cognition, most areas are only assessed by a single exercise, often with only two possible scores (0 or 1). Comparisons with a normative population, such as standard scores and percentiles, are not easily available, leaving only a total score to compare to a cutoff.
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Uncertain cutoffs: The standard cutoff of <26 for MCI is often questioned, with different studies recommending different cutoffs. Many patients are considered borderline if they are close to the cutoff, which leaves healthcare providers with no clear answers. Diverse populations can also be a problem for the MoCA. A crude correction of adding 1 point for patients with lower education is often applied, but there is no simple method for determining a patient-specific cutoff that accounts for the demographic factor with the most potent effect on cognition: age.
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Educational bias: The MoCA was normed in a highly educated population. Some items on the test may be influenced by a patient's educational background, potentially leading to inaccurate results for individuals with lower education levels.
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Inaccurate for certain populations: A study found that MoCA tests administered in diverse urban communities resulted in a significant number of false positives for cognitive impairment. In realistic old-age psychiatric settings, specificity may not be as high as in lab-based estimates, suggesting that over-reliance hitting a cutoff on the MoCA for a diagnosis can be problematic. Furthermore, it is only validated for adults age 55 to 85, making it inappropriate for assessing deficits due to early-onset dementia or other causes, such as head injuries.
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Requires training for interpretation: Interpreting a patient's answers to determine MoCA test results requires certification training. Even so, interpretations may still vary depending on the test administrator's experience and the patient being assessed, potentially leading to inconsistent results.
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Affected by mental health conditions: Certain mental health conditions—like depression which is often comorbid with dementia—can affect or impair cognitive performance, meaning that the MoCA alone may not be able to identify the cause of symptoms. In other words, it may be an inaccurate tool for these patients.
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Inappropriate for long-term monitoring: The MoCA’s simple exercises can be prepared for or memorized, especially after taking it for the first time. Though there are multiple forms available, practice effects can still make interpretation difficult when doing repeat testing.
Comparing Creyos and the MoCA
While the MoCA can be a useful tool to screen for cognitive impairment in patients, it takes more work on the PCP’s part to make it function effectively and accurately.
To do so, they need to be:
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Trained and certified to interpret MoCA test results
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Ensure that they’re accounting for potential mental health conditions in a patient
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Refer patients (if MCI is detected) for a prolonged neuropsychological examination that may cause them undue stress
And even if a PCP follows these steps, there's always a small chance that the results of the MoCA may be inaccurate due to factors like education, cultural background, or early symptoms that go undetected.
While the MoCA is used in many practices offering cognitive screening, PCPs may want to consider additional options, like the Creyos cognitive assessments. These computerized neuropsychological assessments offer a more detailed report compared to the MoCA and MMSE, while also being patient-friendly and immediate.
In one study comparing the MoCA and Creyos tests, patients who were borderline—close to the cutoff on the MoCA—could be more confidently classified as impaired or unimpaired using a short set of Creyos tasks.
For practices using the MoCA, the Creyos assessments bridge the gap between an initial screening test (like the MoCA) and neuropsychological exam, allowing providers to easily incorporate them into a more thorough testing process. Additionally, the results are easy to interpret, don't require special training, and are instantly tabulated and compared to a diverse 85,000+ person normative database for demographic-specific results and pinpoint precision.
Introducing Creyos Dementia Screening, Assessment, and Care Plan
Creyos has a variety of cognitive solutions available for you to expedite the screening and diagnostic process, deliver accurate results, and support patient care and quality-of-life. Each tool is more detailed than traditional screeners like the MoCA and quicker than full neuropsychological exams, while also being available through the convenience of an online telemedicine-friendly platform.
Screen
A two-task cognitive screener that is comparable to the MoCA, but takes less than three minutes to complete. The Creyos dementia screener uses machine learning to detect subtle signs of cognitive impairment, and doesn't require training to interpret. The screening results will indicate whether further testing is recommended to aid in the potential diagnosis of MCI or dementia.
Assess
If further testing is required, Creyos has a 20 minute assessment that provides detailed information about cognition which may assist with an accurate diagnosis. The test is a highly sensitive and scientifically validated six-task protocol. Once complete, it generates an easy-to-interpret report based on DSM-5 criteria for mild and major neurocognitive disorder, allowing healthcare providers to quickly gain much of the information comparable to a neuropsychological exam, informing diagnosis, monitoring, and treatment plans.
Care
Once a diagnosis is reached, Creyos comes with a built-in cognitive care plan. The care plan is based on guidelines by the Alzheimer's Association, and allows PCPs to provide support for caregivers and enhance patient quality of life from the comfort of their own home. After a care plan is in place, cognitive assessment can be repeated to track treatment effectiveness and monitor patient symptoms over time, so PCPs can collect longitudinal data and make objective clinical decisions about next steps.
When to Use Creyos
The Creyos Health platform is flexible enough to assess cognitive function in a wide variety of patients and use cases. For example, the two-task screener can be used either as an alternative to the MoCA, or as a way of gaining additional information after a MoCA test. And, unlike the MoCA, the 20-minute Creyos assessment can be used to gain detailed information about multiple cognitive domains, compare the patient to age-matched norms, and can include mental health questionnaires, allowing PCPs to consider a patient's mental health conditions when assessing cognitive deficits
Compared to traditional cognitive tests like the MoCA or MMSE, the computerized cognitive testing at Creyos is able to provide healthcare professionals with more detailed insight into a patient's cognition while giving them the benefit of being tested at their own convenience.
Additional Benefits of Creyos Health
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Scientifically robust tests with objective results
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Gamified, accessible, and approachable user experience for patients and clinicians
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Non-memorizable and ideal for retesting
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Healthcare recommendations and clear next steps after every test
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Electronic medical record (EMR) integrations
Bridging the Cognitive Care Gap
While the MoCA is an accurate test when used as an initial screening tool for existing MCI, its disadvantages make it less appropriate as a diagnostic tool for MCI and dementia.
Instead of relying solely on the MoCA, consider bridging the dementia detection gap with highly sensitive computerized assessments. With digitized testing, primary care providers can increase the chances for early detection of MCI, expedite diagnosis, and enhance their patient's quality of life by getting them the right care before the disease progresses.
This post was edited by Mike Battista, Director of Science and Research at Creyos (formerly Cambridge Brain Sciences).