MMSE vs.

MoCA: What You Should Know

By Lindsey Getz
The Montreal Cognitive Assessment, used to evaluate cognitive abilities, can better discern
some deficits than the Mini-Mental State Exam.
In the past, testing for Alzheimers disease and other cognitive issues often meant turning to
the Mini-Mental State Exam (MMSE) before any further testing was undertaken. Created by
renowned psychiatrist Marshal Folstein, MD, and introduced in 1975, the MMSE tests
cognitive function by examining orientation, word recall, language abilities, attention and
calculation, and visuospatial ability.
Today, the Montreal Cognitive Assessment (MoCA), a newer test created in 1996, is also
available. Assessing many of the same areas as the MMSE, the MoCA is a little more in
depth and includes tasks such as a clock-drawing test and a trail test (connecting the dots).
The MoCA is newer to the scene and originally just looked at patients with milder forms of
Alzheimers, explains Stephanie Lessig, MD, an assistant clinical professor at UCSD
Neurosciences and VA Medical Center, who was lead author on a comparative study
examining the use of the MoCA vs. the MMSE in patients with Parkinsons. The MoCA has
since gone on to be used for other diseases as well. It seems to be a little better at looking in
depth at some of the deficits that the MMSE might not pick up. For instance, the MMSE has
a heavy language component, but thats not an area that tends to be as much a deficit [in the
early stages] of conditions like Parkinsons or other forms of dementia, so thats where the
MoCA comes in at being a little more sensitive.
Lessigs study found that the MoCA is more sensitive to subtle cognitive deficits in patients
with Parkinsons disease compared with the MMSE, though the MMSE is the more
commonly used test.
Like any test, especially those assessing cognitive abilities, the thought of participating can
make older adults anxious. Physicians say caretakers and other professionals can help put
their patients at ease by stressing that these tests are only meant to help.

Similar But Different

Both the MMSE and the MoCA are routine cognitive screening tests rated on a 30-point
scale. They are both brief, though the MMSE is a little shorter, taking about seven to eight
minutes to administer. The MoCA takes approximately 10 to 12 minutes. Neither test is very
detail oriented and both would likely be used only for initial screening.
Many memory clinics and neurologists administer both tests as well as a host of others. More
pressed for time, an internist or a primary care physician would likely conduct only one
probably the MMSEwhich would be periodically repeated to test for potential decline.

Thats certainly fine as a composite measure over time, but the MMSE is relatively
insensitive to mild disease, says Roy Hamilton, MD, MS, an assistant professor of
neurology at the University of Pennsylvania in Philadelphia. Patients with only minor
cognitive impairment may be overlooked if this is the principal screening tool used.
Their varying degrees of sensitivity create the biggest difference and likely become the
biggest factor for determining which one is used.
For mild impairment, the MoCA is the better test, says Abhay Moghekar, MBBS, an
assistant professor of neurology at The Johns Hopkins University School of Medicine in
Baltimore. Its the more sensitive of the two and also more difficult. So if a physician has a
patient come in with minimal complaints and questions whether its affected him or her
functionally, the physician would likely choose the MoCA. If a patient comes in and is
clearly functionally impaired, theres no need for that highly sensitive test.
The MoCA discriminates very well between normal cognition and mild impairment or
dementia, but its too difficult for moderate to severe conditions, says Barbara MessingerRapport, MD, PhD, director of the Center for Geriatric Medicine at the Cleveland Clinic.
The questions are harder, though it does have some of the same testing elements as MMSE,
such as orientation to time, date, and place. And like the MMSE, MoCA also tests for recall,
but instead of having to remember three items like you would on MMSE, youre asked to
remember five.
MoCA is noteworthy for being more sensitive and therefore able to pick up on things the
MMSE might miss, adds Hamilton. It has been validated in patients who may not be
currently demented but are at the risk of progressing and getting worse.
Overall, the MMSE is likely a better test for more severe conditions, but Messinger-Rapport
says there is a ceiling and floor effect to all tests. The ceiling for MMSE is that a highly
educated person may score well on the MMSE but not be able to recognize their
grandchildren, she says.
Its also important to note that the MMSE, and to a degree the MoCA, were not designed to
be differential diagnostic tools for disambiguating between different types of cognitive
conditions, adds Hamilton. On their own, screening measures like these are poor at
determining if a patient has Alzheimers or a different degenerative disease, such as
frontotemporal dementia. More testing would be required. For instance, when a patient comes
to the Penn Memory Center, theyll get the MoCA and the MMSE, but theyll also get a much
more extensive battery of testing. Without doing a variety of tests, some issues can be
missed.

Calming the Nerves

The idea of undergoing testing for possible cognitive impairment is often daunting to older
patients, who may become nervous and worry that their anxiety will only make the results
worse. But a certain amount of anxiety is ubiquitous to these tests, says Hamilton. We do
take that into account when theyre being completed and to some extent, this anxiety is built
into the performance norms for the measures since just about everyone is nervous during
these tests. We always reassure patients that this is not a pass-fail test, he explains.

Messinger-Rapport makes an effort to reassure patients and says its common to find that
theyre nervous prior to testing. While patients may actually try to practice at home by
going through some of the test questions or try to memorize the answers, this effort will only
skew the test by providing false results and could hurt the patient in the long run.
These tests are meant to help us track a patients cognition over time and help them if theres
a need, Messinger-Rapport explains. We certainly dont want patients to be uncomfortable.
Getting an answer wrong or a low score does not mean a patient is stupid. We make sure they
realize that.
Hamilton says patients should remember they wouldnt be participating in the testing in the
first place if they or a caregiver didnt recognize there was some cause for concern. Thats
what makes it important to complete these tests so the patient can receive help if its needed.
I believe tests like this are a way to objectify and quantify something that is already a
concern and complaint, Hamilton says. These patients wouldnt be coming to the memory
center if they didnt have some sort of concern. So in a way, its that history that is the
evidence of an issue. The test is only a way to translate those concerns into an objective
language. Tests can be helpful in making a diagnosis, but it typically requires the patient or
their loved ones noticing a problem in the first place. Its only meant to help.
Lindsey Getz is a freelance writer based in Royersford, Pa