Lowered MoCA Cut Points Enhance Cognitive Impairment Detection

A new study aimed to investigate the efficacy and discriminative validity of the Spanish and English versions of the Montreal Cognitive Assessment (MoCA) in identifying cognitive impairment among a diverse community of older adults. With concerns about the suitability of the MoCA in ethnoculturally and linguistically diverse settings, the researchers set out to examine whether the current cut points for cognitive impairment are appropriate for a population with varied cultural and linguistic backgrounds.

Results revealed current cut points may lead to a high false-positive rate, prompting a call for lower thresholds in both language versions to enhance diagnostic accuracy. These findings underscore the imperative of tailoring cognitive assessments for diverse populations, shedding light on the need for precision in identifying cognitive decline among older adults with varying cultural and linguistic backgrounds, the study stated.

The investigation included 231 participants 65 years and older who were attending outpatient primary care in the Bronx, New York, and had cognitive concerns. The participants underwent cognitive screening using both MoCA and neuropsychological measures, administered in either Spanish or English. A neuropsychologist then determined the cognitive status of each participant, categorizing them into groups of normal with subjective cognitive concerns (SCC), mild cognitive impairment (MCI), or dementia. The researchers utilized one-way analysis of variance to compare cognitive statuses and performed receiver operating characteristic (ROC) analyses to identify optimal MoCA cut points for discriminating possible cognitive impairment.

The final study population comprised 231 older adults with a mean (SD) age of 72.8 (5.9) years, with women constituting 72% of the participants. The mean (SD) education level was 11.2 (4.2) years. Ethnicity distribution revealed that 42.4% identified as Hispanic and 38.5% identified as Black/African American. Notably, the English-speaking group had a significantly higher average education level (12.6 years) compared with the Spanish-speaking group (9.8 years) (P < .001).

Language, Race, and Ethnicity

A majority of self-identified Hispanic individuals (87%) opted for testing in Spanish, while 89% of African American/Black individuals chose English testing. The English MoCA average was significantly higher at 18.6, compared with the Spanish MoCA average of 16.7 (P < .001).

Cognitive Status and MoCA

The overall mean (SD) MoCA score was 17.7 (4.3), ranging from 6 to 28. Neuropsychological testing identified 39% of participants as "cognitively normal/SCC," 58% as "MCI," and 3% as "dementia." The MoCA scores demonstrated significant differentiation between cognitive status levels (P < 0.001). Using the MoCA cut points proposed by Milani et al revealed a stark contrast, with only 10% classified as "cognitively normal" and 38% as "dementia," highlighting a significant discrepancy compared with neuropsychological tests.

Language of MoCA and ROC Curve Analyses

The English MoCA average (18.6) was significantly higher than the Spanish MoCA average (16.7) (P < .001). After accounting for education, the language of the MoCA test ceased to be a significant factor (P = .205). ROC analyses, combining MCI and dementia, demonstrated an area under the curve of 0.785 for the English MoCA and 0.789 for the Spanish MoCA. Optimal cut points for identifying cognitive impairment were 18.5 for English (sensitivity, 0.646; specificity, 0.774) and 16.5 for Spanish (sensitivity, 0.644; specificity, 0.729).

Comparison With Published Cut Points

The researchers found that previously published cutpoints exhibited good sensitivity but poor specificity for identifying cognitive impairment in the English MoCA, with particularly poor specificity in the Spanish MoCA.

Ultimately, the study concluded both the English and Spanish MoCA had adequate diagnostic accuracy in a population of culturally, educationally, and linguistically diverse older adults presenting to primary care with baseline cognitive concerns.

"However, as hypothesized, currently published cutpoints poorly discriminated cognitively impaired individuals from cognitively normal/SCC individuals in our ethnically/racially diverse sample, with a very high false-positive rate (79%)," the researchers wrote.

Reference

Stimmel MB, Orkaby AR, Ayers E, Verghese J, Nsubayi CK, Weiss EF. Is the Montreal Cognitive Assessment culturally valid in a diverse geriatric primary care setting? lessons from the Bronx. J Am Geriatr Soc. Published online January 10, 2024. doi:10.1111/jgs.18705