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