Identification of Cognitive Impairment After Acute
Stroke Using the Montreal Cognitive Assessment
Sandra J. Stein1, Elena Pace1, Brian F. Olkowski1, Geri Sanfillippo2
Mandy J. Binning2, Erol Veznedaroglu2, Kenneth M. Liebman2
Department of Rehabilitation1 and Capital Institute for Neurosciences2, The Comprehensive Stroke Center at Capital Health
Background
Methods
Results
Conclusion
Unfortunately, many patients with stroke
experience cognitive impairment. Early
identification of cognitive impairment after stroke
is important for ensuring that patients receive the
most appropriate level of rehabilitation after
discharge from the acute care hospital. The Joint
Commission has incorporated the identification
of cognitive impairment into the accreditation
standards for comprehensive stroke centers.
Traditionally, cognitive impairment after stroke
has been identified by the Mini-Mental State
Exam or non-standardized methods. The
Montreal Cognitive Assessment (MoCA) has
been shown to be effective in identifying mild
cognitive impairment in patients with stroke.
Physical, occupational and speech therapists
identified patients with cognitive decline using a
non-standardized process within the first 24
hours of admission. The MoCA was administered to the same patients. Patients scoring less
than 27 were considered to have cognitive impairment. The rehabilitation therapists were
blinded to the results of the MoCA.
Fifty one percent of patients were identified as
having cognitive impairment using the
subjective, non-standardized method. In
comparison, 95% of patients were identified as
having cognitive impairment using the MoCA.
The MoCA identified more patients with
cognitive impairment early after acute stroke
compared to a non-standardized, subjective
process. In addition, administration of the MoCA
was feasible in the acute care setting.
Objectives
The purpose of this study was to:
 Determine the feasibility of administering
the MoCA in the acute care hospital.
 Compare the MoCA to a non-standardized
process for identifying cognitive impairment
soon after stroke.
Methods
During a 4-week period, patients admitted to the
Comprehensive Stroke Center at Capital Health
with the diagnosis of acute stroke were
screened for cognitive impairment using both a
non-standardized process and the MoCA.
Non-standard
Results
0
Thirty-nine patients with acute stroke were
included in the study. The average MoCA score
was 13. On average, the MoCA was administered 3.5 days after admission. No formal score
was obtained from the subjective method.
Gender, n, %
Female
Male
13 (33.3)
26 (66.6)
Age, (x̄)
65.5
Stroke Type, n, %
Ischemic
Hemorrhagic
28 (71.1)
11 (28.2)
NIHSS (admission), (x̄)
8.6
14 (35.9)
25 (64.1)
20
40
60
80
100
Cognitive Impairment (%)
Discussion

Demographics
Discharge Destination, n, %
Community
Inpatient Rehabilitation Facility
References
MoCA


The MoCA identified a greater proportion of
patients with cognitive deficits, making it better in identifying higher level skill deficits.
The MoCA was administered quickly and
easily, making it an appropriate tool for use in
the acute care hospital. As well, intra- and
inter-rater variability may be lower as expected for a scored, quantitative assessment.
The score for identifying cognitive impairment
using the MoCA may be overly sensitive. It
has been suggested that a lower passing
score of 20 would improve the selectivity of
identifying individuals with cognitive impairment. If this criteria were applied to the current study, the identification rate of patients
with cognitive impairment would have decreased from 95% to 85%.
Nasreddine ZS, et al. The Montreal Cognitive
Assessment (MoCA): a brief screening tool for
mild cognitive impairment. J Am Geriatr Soc
53:695–699, 2005
Waldron-Perrine B, et al. Determining an
appropriate cutting score for indication of
impairment on the Montreal Cognitive
Assessment. Int J Geriatr Psychiatry. 2012;27
(11):1189-94.
Penglebury ST, et al. Underestimation of
cognitive impairment by mini-mental state
examination versus the Montreal cognitive
assessment in patients with transient ischemic
attack and stroke: a population-based study.
Stroke. 2010;41:1290-1293.
Acknowledgement
The authors would like to thank staff from the
Department of Rehabilitation at Capital Health
Regional Medical Center for their participation in
this study.