The Montreal Cognitive

Assessment (MoCA)
Masita Rahman
201810401011078
• The Montreal Cognitive Assessment (MoCA) was
designed as a rapid screening instrument
for mild cognitive dysfunction. It assesses
different cognitive domains: attention and
concentration, executive functions, memory,
language, visuoconstructional skills, conceptual
thinking, calculations, and orientation.
MoCA
Pros Cons
• Much more sensitivitive than • Takes 10-14 min to administer
MMSE for MCI and early • More complex administration
dementia and direction than MMSE
• More content tapping higher
level executive function
• 30-point scale similar to
MMSE
• Translation available in 35+
languages
Screening Tool Selection
Montreal Cognitive Assesment (MoCA)
• Sensitivity : 90% for MCI, 100% for
dementia
• Specificity : 87%
St. Louis University Mental Status (Slums)
• Sensitivity : 92% for MCI, 100% for
dementia
• Specificity : 82%
Mini-Mental Status Exam (MMSE)
• Sensitivity : 18% for MCI, 78% for
dementia
• Specificity : 100%
Montreal Cognitive
Assesment (MoCA)
Visuospatial/Executive
1. Alternating Trail Making
Administration: The examiner instructs the subject:
"Please draw a line, going from a number to a letter in
ascending order. Begin here [point to (1)] and draw a
line from 1 then to A then to 2 and so on. End here
[point to (E)]."

Scoring: Allocate one point if the subject successfully

draws the following pattern: 1 −A- 2- B- 3- C- 4- D-
5- E, without drawing any lines that cross. Any error
that is not immediately self-corrected earns a score of
0.
the trail making test requires mental flexibility to
shift between numbers and letters which mainly
rely on frontal lobe function (the left dorsolateral
and medial frontal cortices, right inferior and
middle frontal cortices, right precentral gyrus)
2. Visuoconstructional Skills (Cube):
Visuoconstructional Skills (Cube): Administration: The
examiner gives the following instructions, pointing to the
cube: “Copy this drawing as accurately as you can, in the
space below”.

S coring : One point is allocated for a correctly executed

drawing.
• Drawing must be three-dimensional
• All lines are drawn
• No line is added
• Lines are relatively parallel and their length is similar
(rectangular prisms are accepted) A point is not assigned if
any of the above-criteria are not met.
This ability is enhanced by learning experiences.
After spatial planning, visuomotor coordination
also plays a role in copying the cube. Various brain
areas are involved; visual perception in the
parieto-occipital lobe, planning in the frontal lobe,
and integration of visual and fine motor sequences
in the fronto-parieto-occipital cortices.
3. Visuoconstructional Skills (Clock):
Administration: Indicate the right third of the space and give the
following instructions: “Draw a clock. Put in all the numbers and set
the time to 10 after 11”.
Scoring : One point is allocated for each of the following three
criteria:
Contour (1 pt.): the clock face must be a circle with only minor
distortion acceptable (e.g., slight imperfection on closing the circle);
Numbers (1 pt.): all clock numbers must be present with no additional
numbers; numbers must be in the correct order and placed in the
approximate quadrants on the clock face; Roman numerals are
acceptable; numbers can be placed outside the circle contour;
Hands (1 pt.): there must be two hands jointly indicating the correct
time; the hour hand must be clearly shorter than the minute hand;
hands must be centred within the clock face with their junction close
to the clock centre. A point is not assigned for a given element if any of
the above-criteria are not met.
In fMRI demonstrated bilateral activation of the
posterior parietal cortex and the dorsal premotor
area during task performance suggesting the
contribution of the parieto-frontal cortical
networks to integrate visuospatial elements and
motor control in self-initiated clock drawing.
patients error in CDT were mainly conceptual and
due to semantic memory impairment
Naming
Administration: Beginning on the left, point to
each figure and say: “Tell me the name of this
animal”.

S coring : One point each is given for the

following responses: (1) camel or dromedary, (2)
rhinoceros or rhino, (3) lion.
The neuronal network involved in naming is
category-dependent. the commonly activated
regions were bilateral occipital lobes including the
fusiform gyrus, and pars triangularis of the left
inferior frontal gyrus.
Memory
Administration: The examiner reads a list of 5 words at a rate of
one per second, giving the following instructions: “This is a
memory test. I am going to read a list of words that you will
have to remember now and later on. Listen carefully. When I
am through, tell me as many words as you can remember. It
doesn’t matter in what order you say them”. Mark a check in
the allocated space for each word the subject produces on this
first trial. When the subject indicates that (s)he has finished
(has recalled all words), or can recall no more words, read the
list a second time with the following instructions: “I am going to
read the same list for a second time. Try to remember and tell
me as many words as you can, including words you said the first
time.” Put a check in the allocated space for each word the
subject recalls after the second trial. At the end of the second
trial, inform the subject that (s)he will be asked to recall these
words again by saying, “I will ask you to recall those words again
at the end of the test.”

S coring : No points are given for Trials One and Two.

Attention
Digit Span
Forward Digit Span: Administration: Give the following
instruction: “I am going to say some numbers and when I
am through, repeat them to me exactly as I said them”.
Read the five number sequence at a rate of one digit per
second. Backward Digit Span: Administration: Give the
following instruction: “Now I am going to say some more
numbers, but when I am through you must repeat them to
me in the backwards order.” Read the three number
sequence at a rate of one digit per second.

Scoring: Allocate one point for each sequence correctly

repeated, (N.B.: the correct response for the backwards
trial is 2-4-7).
In healthy subjects, using near-infrared
spectroscopy (NIRS) a relationship between
activation of the right dorsolateral prefrontal
cortex and performance on DSB was observed.
Other studies have shown greater activation of the
bilateral dorsolateral prefrontal cortices,
prefrontal cortex and left occipital visual regions.
Vigilance
Administration: The examiner reads the list of
letters at a rate of one per second, after giving the
following instruction: “I am going to read a
sequence of letters. Every time I say the letter A,
tap your hand once. If I say a different letter, do
not tap your hand”.

Scoring: Give one point if there is zero to one

errors (an error is a tap on a wrong letter or a
failure to tap on letter A).
Concentration, which is defined as sustained and
focused attention, is the primary function
required for proper identification of letter A and
inhibition of inappropriate non-letter A tapping. It
has good sensitivity to cognitive impairment in
mild traumatic brain injury and persistent post-
concussion syndrome.
Serial 7s:
Administration: The examiner gives the following instruction: “Now,
I will ask you to count by subtracting seven from 100, and then, keep
subtracting seven from your answer until I tell you to stop.” Give
this instruction twice if necessary.

Scoring: This item is scored out of 3 points. Give no (0) points for no
correct subtractions, 1 point for one correction subtraction, 2 points
for two-to-three correct subtractions, and 3 points if the participant
successfully makes four or five correct subtractions. Count each
correct subtraction of 7 beginning at 100. Each subtraction is
evaluated independently; that is, if the participant responds with an
incorrect number but continues to correctly subtract 7 from it, give a
point for each correct subtraction. For example, a participant may
respond “92 – 85 – 78 – 71 – 64” where the “92” is incorrect, but all
subsequent numbers are subtracted correctly. This is one error and
the item would be given a score of 3.
In normal subjects, bilateral parietal and
prefrontal cortices have been reported to be
consistently activated during mental calculation,
along with left inferior frontal lobe and angular
gyrus activation
Language
1.Sentence repetition:
Administration: The examiner gives the following
instructions: “I am going to read you a sentence. Repeat it
after me, exactly as I say it [pause]: I only know that John
is the one to help today.” Following the response, say:
“Now I am going to read you another sentence. Repeat it
after me, exactly as I say it [pause]: The cat always hid
under the couch when dogs were in the room.”

Scoring: Allocate 1 point for each sentence correctly

repeated. Repetition must be exact. Be alert for errors
that are omissions (e.g., omitting "only", "always") and
substitutions/additions (e.g., "John is the one who helped
today;" substituting "hides" for "hid", altering plurals,
etc.).
Sentence repetition assesses language skills which
are supported by left temporo-parietal-frontal
circuit. Repeating complex sentences also requires
attention and concentration to memorize the
words which are supported by working memory
systems in the frontal lobes
2. Verbal fluency:
Administration: The examiner gives the following
instruction: “Tell me as many words as you can think of
that begin with a certain letter of the alphabet that I will
tell you in a moment. You can say any kind of word you
want, except for proper nouns (like Bob or Boston),
numbers, or words that begin with the same sound but
have a different suffix, for example, love, lover, loving. I
will tell you to stop after one minute. Are you ready?
[Pause] Now, tell me as many words as you can think of
that begin with the letter F. [time for 60 sec]. Stop.”

Scoring: Allocate one point if the subject generates 11

words or more in 60 sec. Record the subject’s response in
the bottom or side margins.
Letter F fluency in the MoCA mainly depends on frontal
lobe function which is sustained by both temporal and
frontal lobes. Letter F fluency requires coordination of
lexicosemantic knowledge, shifting from word to word,
working memory, searching strategy and inhibition of
irrelevant words which all highly depend on frontal lobe
function and the temporal lobe.
Abstraction
 Administration: The examiner asks the subject to explain
what each pair of words has in common, starting with the
example: “Tell me how an orange and a banana are alike”.
If the subject answers in a concrete manner, then say only
one additional time: “Tell me another way in which those
items are alike”. If the subject does not give the
appropriate response (fruit), say, “Yes, and they are also
both fruit.” Do not give any additional instructions or
clarification. After the practice trial, say: “Now, tell me
how a train and a bicycle are alike”. Following the
response, administer the second trial, saying: “Now tell me
how a ruler and a watch are alike”. Do not give any
additional instructions or prompts.
Scoring: Only the last two item pairs are scored. Give 1
point to each item pair correctly answered. The following
responses are acceptable: Train-bicycle = means of
transportation, means of travelling, you take trips in both;
Ruler-watch = measuring instruments, used to measure.
The following responses are not acceptable: Train-bicycle
= they have wheels; Ruler-watch = they have numbers.
Similarity between objects requires semantic
knowledge and conceptual thinking. Frontal
executive function and the parietotemporal
semantic knowledge involved in this task for more
difficult and demanding word pairs
Delayed Recall
Delayed recall
Administration: The examiner gives the following
instruction: “I read some words to you earlier,
which I asked you to remember. Tell me as many
of those words as you can remember. Make a
check mark (3) for each of the words correctly
recalled spontaneously without any cues, in the
allocated space.

Scoring: Allocate 1 point for each word recalled

freely without any cues.
Retrieval memory impairment may be associated with
medial parietal and frontal white matter loss, posterior
cingulate hypometabolism, pathologies affecting
subcortical structures, hippocampal-parieto-frontal
network. Retrieval memory deficits are seen in pathologies
affecting sub-cortical structures such as Vascular Cognitive
Impairment, Parkinson’s disease, Huntington’s disease.
Orientation:
Orientation:
Administration: The examiner gives the following
instructions: “Tell me the date today”. If the subject
does not give a complete answer, then prompt
accordingly by saying: “Tell me the [year, month,
exact date, and day of the week].” Then say: “Now,
tell me the name of this place, and which city it is in.”

Scoring: Give one point for each item correctly

answered. The subject must tell the exact date and
the exact place (name of hospital, clinic, office). No
points are allocated if subject makes an error of one
day for the day and date.
Impairment in orientation has been shown to be the single
best independent predictor of daily functions in patients
with dementia, and is also associated with caregiver
burden and psychological distress. Temporal orientation
yields high sensitivity in detection of dementia and
patients with delirium. However, orientation is not a good
indicator to detect milder stages of cognitive impairment.
TOTAL SCORE: Sum all subscores listed on the
right-hand side. Add one point for an individual
who has 12 years or fewer of formal education, for
a possible maximum of 30 points. A final total
score of 26 and above is considered
normal.