Montreal Cognitive Assessment (MoCA): Administration and Scoring

Instructional webinar on the administration and scoring of the Montreal Cognitive Assessment (MoCA). To see the MoCA being administered to a real patient in a clinic setting, watch the MoCA demonstration video with Sam at: https://www.youtube.com/watch?v=ryf8SG0NQLQ

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.