The Montreal Cognitive Assessment May Not Be an Effective Screening
Tool in Low Income Countries with Education Inequality
Laura Santoso1, Emily Erkkinen1, Carlos Adon2
1: University of Massachuestts Medical School, Worcester, MA, USA. 2: Instituto Dominicano de Estudios Virologicos, Santo Domingo, Dominican Republic.
Objectives
Results
Discussion
• To gauge the qualitative value of the Montreal Cognitive
Assessment (MoCA) as a screen for HIV-associated
neurocognitive disorder (HAND)
• To assess potential use of the MoCA in regular care at an
infectious disease clinic in Santo Domingo, Dominican Republic
(DR)
• 84 of 95 patients screened had abnormal cognition using the
original MoCA scoring system (MoCA score < 26, add 1 point if
≤ 12 years education)
• Standard deviations were >3 points at all education levels (4.7,
3.1, 4.9, 3.4 respectively)
• Using analysis of variance, the mean MOCA scores of the four
education groups were significantly different from one another
with means of 14.8, 17.3, 19.0, and 22.3 respectively
(p<0.001).
ANALYSIS
• The MoCA has limited qualitative value for clinical use in HIV
patients in Santo Domingo, DR.
• As 84 of 95 patients screened positive for abnormal cognition,
the MoCA appears to be highly nonspecific at this clinic.
• Significant differences in mean performance between all four
education groups suggest insufficient point scaling.
• Large standard deviations in scores suggest a cutoff line may
not reliably differentiate normal from abnormal cognition.
• The dependence between failing certain MoCA tasks and
education level illustrates that education level is a significant
confounding factor for pure pathologic cognitive impairment.
• HIV causes cognitive impairment in approximately half of
patients.
• Populations without dependable access to treatment are at
higher risk for HIV-associated dementia.
• The MoCA has been validated in North America to screen for
mild cognitive impairment and dementia in various neurologic
diseases.
• Validation studies of the MoCA outside North America and
Europe and for use to detect HAND are limited.
• Studies in China, Sri Lanka, and Colombia suggest changing
scoring to better fit the population.
• There are no studies of the MoCA in the DR.
Methods
• 95 random HIV positive
patients completed the
MoCA-Spanish and an oral
questionnaire.
• Education level was
grouped according to
grades of schooling
completed: 0-4, 5-8, 9-12,
and any amount of
university.
• Patients were excluded if
they had history of
cognitive impairment from
a non HIV cause.
Montreal Cognitive Assessment Scores
and Education Level
30
MoCA Score
Background
25 = MoCA
cutoff for
abnormal
cognition for
people with <12
years of
education
25
20
15
10
5
0
Grades 1-4 Grades 5-8 Grades 9- University
(n=12)
(n=15)
12 (n=34)
(n=23)
Figure 1: Average Montreal Cognitive Assessment Scores and
Education Level
• Using Fisher’s exact test, failing the MoCA tasks below was
shown to be dependent on education level:
•
•
•
•
•
•
Trail-making B (p=0.03)
Clock drawing (p<0.01)
Animal naming (p=0.01)
Letter detection using tapping (p<0.01)
Phonemic fluency (p<0.01)
Word association task (p<0.01)
LIMITATIONS
• Lack of control made it difficult to gauge whether low scores
were due to pathologic impairment or normal variability.
• The global diversity of formal education and informal learning
experiences makes screening for pathologic cognitive
impairment challenging.
Future Directions
• Conduct the MoCA or MoCA-basic with healthy subjects in the
Dominican Republic.
• Conduct a true validation study of the MoCA for HAND
comparing results to neuropsychological testing.
• Determine if a different scoring system could appropriately
adjust for education level.
• Develop screens of cognitive function for global use with less
dependence on formal education.
Acknowledgements
• Dr. Ellen Koenig; Instituto Dominicano de Estudios Virologicos
• Dr. Carolina Ionete, Dr. Anindita Deb; University of
Massachusetts Medical School