The topic of this training session is Montreal Cognitive Assessment,
MoCa, Administration and Scoring.
The objectives are to learn how to administer the MoCA, and to understand
the scoring procedures and to interpret a patient's performance on the tool.
And also to practice scoring a sample patient's exam.
Before we start, it would be helpful if you have in front of you both a copy of
the MoCA form as well as the instructions.
You can download both at the website shown on the page.
It's also helpful if you have already viewed the MoCA video with patient Sam and
tried to score his MoCA on your own because we
will go through that a little bit later.
This is a screen shot of what the instrument looks like.
Before administering the MoCA, you wanna make sure you have a patient's full
attention, that you're speaking clearly and
in a reasonable enough volume so that hearing confounds do not become an issue.
Make sure before you start that you record the date, the patient's age, and
level of education at the top of the form because you'll need that information
later when it comes to scoring.
We'll talk a little bit about administration and scoring of the MoCA.
The MoCA is one of the most sensitive, but
also one of the more technical screening instruments to administer.
The instructions are very nuanced, and so it's important to read through them
carefully before actually trying to administer the screen with a patient.
You'll need to know which items can be repeated, and
how questions should be phrased, because this is important for some of the items.
Again, the MoCA instructions are very clear and very exacting.
And therefore, I'm only going to highlight a few administration issues on
some of the items.
Question number one is about trail making.
That is, the patient has to alternate back and forth between numbers and letters.
Note that if a patient self-corrects an error, and recognizes the error,
and changes course, you can give them full credit.
However, uncorrected mistakes of any kind are scored zero points.
Question number three is a clock drawing task.
It's important to keep in mind here that scoring of this clock is
broken up into three separate components, each of which is awarded one point.
Give patients the benefit of the doubt for the contour or the shape of the circle.
This is because in clinical experience, when many patients draw a circle,
they do so rather hastily.
Note also that the hour hand must be shorter than the minute hand.
On other instruments like the mini cog, the length of the hands does not matter.
But for the MoCA, the hand length is incorporated into scoring.
For the word list on question number five, this portion is not scored.
All you're doing here is just allowing the patient to register and
repeat back the words to you.
After the patient has successfully repeated the list two times,
do not forget to say that you will ask for those same words again a little later.
Question number six involves digit span.
Make sure that you say each number separately as in two, one, eight.
And say each number approximately one second apart.
The administration of question number seven is a little tricky because you need
to both fluidly say a string of long letters, and also, at the same time, keep
track of when the patient is responding or tapping to all the letter As.
Make sure that you're positioning the patient's hand closely enough to you so
that you can see their hand in your peripheral vision while you're reading
the letters.
Once you begin reciting the letters, do not stop.
Make sure the presentation is continuous and fluid, without pausing.
For question number 10, which is word recall,
you may not need to do the optional items on this subtest involving
cuing when you're giving the patient reminders.
Only words spontaneously recalled without cues are actually scored and given credit.
And it's only that portion of question number 10 that contributes to
the total score.
The last section of the MoCA question 11 is regarding orientation.
All responses here must be exact to get credit.
For example, if a patient does one or two days off on the date or
day of the week, those responses would receive zero points.
At the end of administration, add up all the items carefully,
double check your addition, make sure that you add one extra point for
patients with a high school education or less.
This is how this instruments accounts for
educational differences that can impact performance.
This is something that can be easily overlooked and
can make the difference between a passing or a failing score.
So try to remember that educational component at the very end.
A passing score on the instrument is a score of 26 or higher.
The MoCA is scored out of a possible 30 points.
A failure is a score of 25 or less.
Hopefully, you have already seen the patient Sam completing the MoCA,
and tried to score his performance yourself.
We will now review his performance and score the instrument together.
For the first couple of items, Sam performed them correctly.
He was able to do the alternating back and forth between numbers and
letters appropriately, and also did reasonably well on the cube copy.
This is a screenshot of Sam's clock.
Note that, like many patients, Sam was a little bit hasty in drawing the circle and
did not fully close the circle at the top.
I, in this case, would give Sam the benefit of the doubt for generally
creating the circle appropriately, and award one point for contour.
Sam also has all the numbers in their correct location with no duplicate
numbers, so he receives another point for the number scoring.
With regard to the hands, you'll note that instead of placing the hands
at 10 past 11, Sam has drawn one hand to the 10 and one to the 11.
This is a more concrete performance, and for
that section would receive zero points.
That means that Sam's total points for the clock draw are two out of three points.
For animal naming, Sam was able to name correctly all of the animals shown on
the page, so he gets full credit for that.
He was also able to appropriately repeat the list of five words on both trials.
For the first component of the attention subtest where Sam was repeating numbers,
he successfully completed both of those correctly, and so
also receives full credit, two out of two points.
During the hand tapping portion, Sam made several mistakes along
the way in response to As that were said by the examiner.
Because he made two or more errors, he received zero points for
this portion of the test.
The next question was about serial sevens.
You'll notice that Sam got some of these correct, but others wrong.
Therefore, he was able to correctly subtract seven two times,
which corresponds to a score of two out of three.
And you can see underneath the numbers
there are instructions about how to score this section.
Under language, Sam was able to repeat both sentences correctly, so
receives two out of two points.
When he was asked to name words in one minute that begin with the letter F,
he was able to name more than eleven, and so receives a full credit, one point.
And for abstraction, for the first item,
train and bicycle, Sam struggled a little bit.
His answer related to wheels that operate in the same way or have elbows.
And that's considered a more concrete response.
The MoCA instructions detail out a little bit more specifically
what is a good response or a bad response.
For that item, the train and bicycle, Sam did not not receive full credit.
But he did answer appropriately when asked about the similarity between a watch
and a ruler.
So he receives one out of a total two points in that direction.
When Sam was asked to remember the words that were given to him earlier,
unfortunately he was not able to remember any of the words, and so
received zero points.
For the last section orientation, Sam was able to answer all of those
questions correctly, and so received six points.
When all of the sub components are added together,
Sam's total score on the MoCA is 21 over 30.
Adding an extra point is not necessary because Sam has more than
a high school education, so his total score is 21 points.
The ACT on Alzheimer's website has many provider tools that simplify
the screening process, and also provide simple instructions for
what to do when patients pass and fail the screen.
For more information to download these free tools,
please visit the ACT on Alzheimer's website at the link provided,
or you can also contact ACT on Alzheimer's staff using
the information on the slide below.