The MoCa (Montreal Cognitive Assessment) Test for Dementia
How can doctors tell whether you are developing dementia? One widely used tool is the Montreal Cognitive Assessment, or MoCA test—a series of questions designed to shed insight into how well your brain handles cognitive tasks. The test is commonly given in a doctor's office and takes about 15 minutes. President Trump says he "aced" this test in 2018, making headlines by discussing how well he remembered five words he had been asked to recall (for example, "person, woman, man, camera, TV").
What other kinds of questions does the MoCA test for dementia ask? And how reliable are this test's results?
The MoCA was created in 1996 by Montreal neurologist Ziad Nasreddine. Over the years, several versions have been developed, including one for those with sight or hearing impairment. Today, the test is used in about 200 countries. MoCA can be given on paper or electronically, but it is designed to be administered by a trained healthcare professional who has been certified in its use and interpretation.
The MoCA test's primary purpose is to detect problems with cognition—how well your brain works to perceive or understand things. Such problems can develop as you age, as part of some illnesses (such as stroke or Parkinson's disease), or following a traumatic brain injury.
The test is not designed to assess your intelligence. Instead, doctors use it as a tool to help diagnose brain conditions, such as mild cognitive impairment (MCI), which often—but not always—progresses into dementia. The test also can help assess whether someone has dementia, such as Alzheimer's disease, and its severity.
The MoCA consists of a series of tasks to see how well your brain is functioning in such cognitive domains as:
- Executive functioning (how well you can focus and reason)
- Immediate and short-term recall
- Visual perception
- Fluency (your understanding of language)
- Calculation (basic math ability)
- Orientation (to time and place)
What kinds of questions can you expect from a MoCA exam? Based on recent MoCA sample tests, here are a few tasks you may be asked to complete:
- Recall five unrelated words, such as: "rose, chair, hand, blue, spoon." (You will be asked to repeat them immediately after the test-taker gives them to you, and then again later, toward the end of the test.)
- Count backwards from 100 by seven. You also may be asked to calculate using currency, such as determining what change you might expect from your $20 bill if you were charged $13.55.
- How many words can you name in one minute that start with F? (Or you might be asked to name words that fit a category, like fruits.)
- Identify animals from pictures (such as a zebra or tiger).
- To test your visual perception, you may be asked to identify objects drawn within a jumble of other objects. Or, you may be asked to draw a picture (such as a cube) based on a drawing shown on the test form.
- The "clock test"—common in many dementia exams—is part of the MoCA dementia test. The test administrator will ask you to draw the face of a traditional (non-digital) clock, as well as to illustrate a specific time.
- Your ability to think abstractly may be tested by asking you to determine the relationships between objects—for instance, how trains and boats are similar to each other.
Studies show the MoCA correctly identifies dementia in 94% of those tested. (Accuracy is determined by comparing an individual's MoCA result to a known clinical diagnosis of dementia, which is a decline in cognitive abilities assessed by a clinician using a mini-neuropsychological series of tests and other factors.) Doctors consider the MoCa much better at detecting mild cognitive impairment than other widely used tests. For example, in one study, the MoCA correctly found mild cognitive impairment in 83% of test-takers, compared to only 17% by the Mini-Mental State Exam (MMSE).
The MoCA places more emphasis on executive functioning tasks than the MMSE. That quality makes it better able to detect dementias other than Alzheimer's, such as Lewy body dementia or frontotemporal lobe dementia. The test also can help predict which patients who already have been diagnosed with mild cognitive impairment are at risk of developing dementia within the next six months.
Montreal Cognitive Assessment scoring is based on a 30-point scale, with points awarded differently depending on the type of question asked. For instance, you can earn one point for each animal you identify in a picture, but listing the names of 13 fruits in under a minute gains you only two points. If you can name eight to 12 fruits, you earn one point; less than eight, and you don't earn any points.
Overall, if you earn 26 to 30 points on the MoCA, you are considered to have normal cognitive abilities (the average score for a control group of non-impaired people taking the test is 27.2). President Trump says he earned a perfect 30 points, which is uncommon. Usually only eight out of 90 people (with an average age of 73) score this highly, according to Dr. Nasreddine, MoCA Test, Inc.
A score of 19 to 25 indicates mild cognitive impairment. Scores of between 11 and 21 suggest mild Alzheimer's disease. There is some overlap between this type of dementia and mild cognitive impairment, reflecting the difficulty in using a single test to make this type of diagnosis.
Indeed, MoCA test results are only one factor that your doctor will consider when making a diagnosis. Your physical state at the time of the exam also can play a role, including medications you may be taking, whether you are tired, and whether you feel ill. Doctors consider other kinds of test results in the diagnosis as well, such as MRI scans or other dementia exams. Scores also may be adjusted based on your education level (those with 12 years of formal education generally have a point added to account for possible education bias in the test design).
Your doctor is your best resource for any questions concerning your—or a loved one's—cognitive state, as well as whether you should take the Montreal Cognitive Assessment. This is not a test you should try to take on your own, but rather under guidance of a certified MoCA examiner.