0:00:00.000,0:00:04.800 The topic of this training session[br]is Montreal Cognitive Assessment, 0:00:04.800,0:00:07.367 MoCa, Administration and Scoring. 0:00:07.367,0:00:11.603 The objectives are to learn how to[br]administer the MoCA, and to understand 0:00:11.603,0:00:16.197 the scoring procedures and to interpret[br]a patient's performance on the tool. 0:00:16.197,0:00:20.231 And also to practice scoring[br]a sample patient's exam. 0:00:20.231,0:00:24.922 Before we start, it would be helpful if[br]you have in front of you both a copy of 0:00:24.922,0:00:27.614 the MoCA form as well as the instructions. 0:00:27.614,0:00:31.236 You can download both at[br]the website shown on the page. 0:00:31.236,0:00:37.199 It's also helpful if you have already[br]viewed the MoCA video with patient Sam and 0:00:37.199,0:00:40.492 tried to score his MoCA[br]on your own because we 0:00:40.492,0:00:43.534 will go through that a little bit later. 0:00:43.534,0:00:46.612 This is a screen shot of what[br]the instrument looks like. 0:00:49.245,0:00:53.453 Before administering the MoCA, you wanna[br]make sure you have a patient's full 0:00:53.453,0:00:56.002 attention, that you're[br]speaking clearly and 0:00:56.002,0:01:00.292 in a reasonable enough volume so that[br]hearing confounds do not become an issue. 0:01:00.292,0:01:04.947 Make sure before you start that you[br]record the date, the patient's age, and 0:01:04.947,0:01:09.674 level of education at the top of the form[br]because you'll need that information 0:01:09.674,0:01:11.623 later when it comes to scoring. 0:01:11.623,0:01:15.258 We'll talk a little bit about[br]administration and scoring of the MoCA. 0:01:15.258,0:01:18.079 The MoCA is one of the most sensitive, but 0:01:18.079,0:01:22.841 also one of the more technical[br]screening instruments to administer. 0:01:22.841,0:01:27.270 The instructions are very nuanced, and[br]so it's important to read through them 0:01:27.270,0:01:31.519 carefully before actually trying to[br]administer the screen with a patient. 0:01:31.519,0:01:34.544 You'll need to know which[br]items can be repeated, and 0:01:34.544,0:01:39.267 how questions should be phrased, because[br]this is important for some of the items. 0:01:39.267,0:01:43.400 Again, the MoCA instructions[br]are very clear and very exacting. 0:01:43.400,0:01:48.246 And therefore, I'm only going to[br]highlight a few administration issues on 0:01:48.246,0:01:49.465 some of the items. 0:01:49.465,0:01:52.330 Question number one is about trail making. 0:01:52.330,0:01:57.690 That is, the patient has to alternate back[br]and forth between numbers and letters. 0:01:57.690,0:02:02.860 Note that if a patient self-corrects[br]an error, and recognizes the error, 0:02:02.860,0:02:06.431 and changes course,[br]you can give them full credit. 0:02:06.431,0:02:11.206 However, uncorrected mistakes of[br]any kind are scored zero points. 0:02:13.435,0:02:14.606 Question number three is[br]a clock drawing task. 0:02:14.606,0:02:19.845 It's important to keep in mind[br]here that scoring of this clock is 0:02:19.845,0:02:26.360 broken up into three separate components,[br]each of which is awarded one point. 0:02:26.360,0:02:31.288 Give patients the benefit of the doubt for[br]the contour or the shape of the circle. 0:02:31.288,0:02:36.261 This is because in clinical experience,[br]when many patients draw a circle, 0:02:36.261,0:02:38.058 they do so rather hastily. 0:02:38.058,0:02:43.381 Note also that the hour hand must[br]be shorter than the minute hand. 0:02:43.381,0:02:47.695 On other instruments like the mini cog,[br]the length of the hands does not matter. 0:02:47.695,0:02:52.234 But for the MoCA, the hand length[br]is incorporated into scoring. 0:02:52.234,0:02:55.769 For the word list on question number five,[br]this portion is not scored. 0:02:55.769,0:03:00.456 All you're doing here is just[br]allowing the patient to register and 0:03:00.456,0:03:02.555 repeat back the words to you. 0:03:02.555,0:03:07.395 After the patient has successfully[br]repeated the list two times, 0:03:07.395,0:03:13.212 do not forget to say that you will ask for[br]those same words again a little later. 0:03:13.212,0:03:15.993 Question number six involves digit span. 0:03:15.993,0:03:21.433 Make sure that you say each number[br]separately as in two, one, eight. 0:03:21.433,0:03:26.432 And say each number[br]approximately one second apart. 0:03:26.432,0:03:30.452 The administration of question number[br]seven is a little tricky because you need 0:03:30.452,0:03:34.412 to both fluidly say a string of long[br]letters, and also, at the same time, keep 0:03:34.412,0:03:38.020 track of when the patient is responding or[br]tapping to all the letter As. 0:03:38.020,0:03:42.942 Make sure that you're positioning the[br]patient's hand closely enough to you so 0:03:42.942,0:03:47.569 that you can see their hand in your[br]peripheral vision while you're reading 0:03:47.569,0:03:48.459 the letters. 0:03:48.459,0:03:51.478 Once you begin reciting the letters,[br]do not stop. 0:03:51.478,0:03:58.289 Make sure the presentation is[br]continuous and fluid, without pausing. 0:03:58.289,0:04:01.860 For question number 10,[br]which is word recall, 0:04:01.860,0:04:06.537 you may not need to do the optional[br]items on this subtest involving 0:04:06.537,0:04:10.208 cuing when you're giving[br]the patient reminders. 0:04:10.208,0:04:15.913 Only words spontaneously recalled without[br]cues are actually scored and given credit. 0:04:15.913,0:04:20.516 And it's only that portion of question[br]number 10 that contributes to 0:04:20.516,0:04:21.673 the total score. 0:04:21.673,0:04:26.631 The last section of the MoCA question[br]11 is regarding orientation. 0:04:26.631,0:04:29.633 All responses here must[br]be exact to get credit. 0:04:29.633,0:04:34.015 For example, if a patient does one or[br]two days off on the date or 0:04:34.015,0:04:38.415 day of the week,[br]those responses would receive zero points. 0:04:38.415,0:04:42.193 At the end of administration,[br]add up all the items carefully, 0:04:42.193,0:04:46.401 double check your addition,[br]make sure that you add one extra point for 0:04:46.401,0:04:49.269 patients with a high school education or[br]less. 0:04:49.269,0:04:52.062 This is how this instruments accounts for 0:04:52.062,0:04:55.904 educational differences that[br]can impact performance. 0:04:55.904,0:04:58.978 This is something that can[br]be easily overlooked and 0:04:58.978,0:05:02.703 can make the difference between[br]a passing or a failing score. 0:05:02.703,0:05:06.275 So try to remember that educational[br]component at the very end. 0:05:07.404,0:05:13.006 A passing score on the instrument[br]is a score of 26 or higher. 0:05:13.006,0:05:16.042 The MoCA is scored out[br]of a possible 30 points. 0:05:16.042,0:05:20.725 A failure is a score of 25 or less. 0:05:20.725,0:05:25.980 Hopefully, you have already seen[br]the patient Sam completing the MoCA, 0:05:25.980,0:05:29.351 and tried to score his[br]performance yourself. 0:05:29.351,0:05:34.129 We will now review his performance and[br]score the instrument together. 0:05:34.129,0:05:38.035 For the first couple of items,[br]Sam performed them correctly. 0:05:38.035,0:05:41.956 He was able to do the alternating back and[br]forth between numbers and 0:05:41.956,0:05:46.236 letters appropriately, and[br]also did reasonably well on the cube copy. 0:05:46.236,0:05:49.111 This is a screenshot of Sam's clock. 0:05:49.111,0:05:54.582 Note that, like many patients, Sam was a[br]little bit hasty in drawing the circle and 0:05:54.582,0:05:57.331 did not fully close the circle at the top. 0:05:57.331,0:06:01.486 I, in this case, would give Sam[br]the benefit of the doubt for generally 0:06:01.486,0:06:05.722 creating the circle appropriately,[br]and award one point for contour. 0:06:05.722,0:06:10.524 Sam also has all the numbers in their[br]correct location with no duplicate 0:06:10.524,0:06:14.858 numbers, so he receives another point for[br]the number scoring. 0:06:14.858,0:06:19.846 With regard to the hands, you'll note[br]that instead of placing the hands 0:06:19.846,0:06:24.770 at 10 past 11, Sam has drawn one[br]hand to the 10 and one to the 11. 0:06:24.770,0:06:27.571 This is a more concrete performance,[br]and for 0:06:27.571,0:06:30.160 that section would receive zero points. 0:06:30.160,0:06:37.365 That means that Sam's total points for the[br]clock draw are two out of three points. 0:06:37.365,0:06:41.763 For animal naming, Sam was able to name[br]correctly all of the animals shown on 0:06:41.763,0:06:44.630 the page, so he gets full credit for that. 0:06:44.630,0:06:51.112 He was also able to appropriately repeat[br]the list of five words on both trials. 0:06:51.112,0:06:57.282 For the first component of the attention[br]subtest where Sam was repeating numbers, 0:06:57.282,0:07:01.691 he successfully completed both[br]of those correctly, and so 0:07:01.691,0:07:05.498 also receives full credit,[br]two out of two points. 0:07:05.498,0:07:10.096 During the hand tapping portion,[br]Sam made several mistakes along 0:07:10.096,0:07:13.966 the way in response to As that[br]were said by the examiner. 0:07:13.966,0:07:18.443 Because he made two or more errors,[br]he received zero points for 0:07:18.443,0:07:20.307 this portion of the test. 0:07:20.307,0:07:23.945 The next question was about serial sevens. 0:07:23.945,0:07:29.193 You'll notice that Sam got some of[br]these correct, but others wrong. 0:07:29.193,0:07:34.170 Therefore, he was able to correctly[br]subtract seven two times, 0:07:34.170,0:07:37.964 which corresponds to a score[br]of two out of three. 0:07:37.964,0:07:41.007 And you can see underneath the numbers 0:07:41.007,0:07:45.582 there are instructions about[br]how to score this section. 0:07:45.582,0:07:49.729 Under language, Sam was able to[br]repeat both sentences correctly, so 0:07:49.729,0:07:51.637 receives two out of two points. 0:07:51.637,0:07:57.459 When he was asked to name words in one[br]minute that begin with the letter F, 0:07:57.459,0:08:03.866 he was able to name more than eleven, and[br]so receives a full credit, one point. 0:08:03.866,0:08:07.525 And for abstraction, for the first item, 0:08:07.525,0:08:11.700 train and bicycle,[br]Sam struggled a little bit. 0:08:11.700,0:08:17.384 His answer related to wheels that[br]operate in the same way or have elbows. 0:08:17.384,0:08:20.393 And that's considered[br]a more concrete response. 0:08:20.393,0:08:25.270 The MoCA instructions detail out[br]a little bit more specifically 0:08:25.270,0:08:28.433 what is a good response or a bad response. 0:08:28.433,0:08:32.826 For that item, the train and bicycle,[br]Sam did not not receive full credit. 0:08:32.826,0:08:36.580 But he did answer appropriately when asked[br]about the similarity between a watch 0:08:36.580,0:08:37.205 and a ruler. 0:08:37.205,0:08:41.634 So he receives one out of a total[br]two points in that direction. 0:08:41.634,0:08:45.668 When Sam was asked to remember the words[br]that were given to him earlier, 0:08:45.668,0:08:49.366 unfortunately he was not able to[br]remember any of the words, and so 0:08:49.366,0:08:50.725 received zero points. 0:08:50.725,0:08:54.654 For the last section orientation,[br]Sam was able to answer all of those 0:08:54.654,0:08:57.649 questions correctly, and[br]so received six points. 0:08:57.649,0:09:01.490 When all of the sub components[br]are added together, 0:09:01.490,0:09:05.159 Sam's total score on[br]the MoCA is 21 over 30. 0:09:05.159,0:09:09.245 Adding an extra point is not[br]necessary because Sam has more than 0:09:09.245,0:09:13.190 a high school education, so[br]his total score is 21 points. 0:09:13.190,0:09:18.147 The ACT on Alzheimer's website has[br]many provider tools that simplify 0:09:18.147,0:09:22.853 the screening process, and[br]also provide simple instructions for 0:09:22.853,0:09:26.396 what to do when patients pass and[br]fail the screen. 0:09:26.396,0:09:31.130 For more information to[br]download these free tools, 0:09:31.130,0:09:37.264 please visit the ACT on Alzheimer's[br]website at the link provided, 0:09:37.264,0:09:42.214 or you can also contact ACT[br]on Alzheimer's staff using 0:09:42.214,0:09:45.567 the information on the slide below.