Development of a Cognitive Screening Test
for the Severely Hearing Impaired
Chung J , Shipp D , Freisen L , Black S ,Maselli M , Lin V
2
1,2
1,2
3,4
3,4
1,2
Cochlear Implant Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
2
Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
3
Department of Neurology, University of Toronto, Toronto, Ontario, Canada
4
Department of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
1
Abstract
Objective: Reliable tests for mild cognitive impairment (MCI) are extremely clinically valuable. No MCI
screening tests exist for those with hearing impairment. Our objective is to validate a modified version
of the Montreal Cognitive Assessment (MoCA) for use in patients with hearing impairment (MoCA-H).
Methods: Older-aged subjects were recruited from outpatient Otolaryngology clinics. A battery of cognitive
screening tools and the MoCA-H were performed on 62 normal hearing subjects and 41 subjects with
severe-to-profound hearing loss (HL). The MoCA was retested 6 months after MoCA-H was administered in a
subset of subjects.
Results: No significant difference was demonstrated between the MoCA-H scores in those with and without
HL. Similar scores were noted between the MoCA-H and MoCA in a subset.
Results
62 subjects were tested in Group #1. 7 were excluded, 4 due to frustration and 3 due to a neurological
disorder or family history of dementia. The average age was 70.9. The average score of patients who
underwent the MoCA-H was 26.6 (SD = 2.04), consistent with the accepted normal cutoff of >26/30. Group #2
consisted of 41 cochlear implant subjects. 1 was excluded due to frustration. The average age was 71.8. No
significant difference was demonstrated between the MoCA-H scores in those with and without HL of those 8
retested (p>0.01). Similar scores were noted between the MoCA-H and MoCA in the subset of normal hearing
subjects that were retested (p>0.01). Further subanalysis of test categories revealed small differences between
the MoCA-H and MoCA. Domains differing between the MoCA-H and MoCA included “Trails”, “Naming”, and
“Memory”.
Conclusion: The MoCA-H results of normal cognitively screen subjects have a high correlation to MoCA
results. The MoCA-H would be an invaluable tool to detect MCI in those with hearing impairment.
Introduction
With the aging of our population and increasing average lifespan, we are increasingly encountering patients
with mild cognitive impairment (MCI)(1). MCI is an intermediate stage on the spectrum of cognitive function
between expected cognitive decline of normal age and more serious decline of dementia (2). Patients may
notice problems with memory, language, thinking and judgment. Dementia is a public concern and experts
have predicted the number of those affected to double every 20 years (1). It has been estimated 81.1 million
people will be affected by dementia by 2040. MCI may increase the risk of progression to Alzheimer’s
dementia
or other neurological conditions (3). Early detection and treatment of MCI and dementia is beneficial
and has a role slowing the progression of the disease process (4).
Screening for MCI is performed by a primary care physician or Neurologist. Common screening tools include
the Montreal Cognitive Assessment (5) and the Folstein Mini Mental Status test (6). The Montreal Cognitive
Assessment is a validated screening tool developed in 2003. It has been adapted and validated in multiple
languages and used worldwide. These commonly utilized validated screening tools for cognitive testing
are excellent at detecting patients presenting with early cognitive decline. These tests, however, rely on the
patient’s ability to follow auditory instructions. No clinical screening test for MCI is available for patients with
severe hearing loss. Our objective is to validate a modified version of the Montreal Cognitive Assessment
(MoCA) for use in patients with hearing impairment (MoCA-H).
Methods
The Montreal Cognitive Assessment was adapted to a visual
slideshow presentation called the Modified MoCA (MoCA-H).
Verbal instructions were translated into digital, visual instruction.
All domains of the MoCA were translated and were reviewed by
two Neurologists. The test was scored out of 30, similar to the
MoCA. Older-aged (>60 years of age) subjects were recruited
from outpatient Otolaryngology clinics and consent was obtained.
Group #1 included those fluent in English, had at least
a Grade 6 education and had no evidence of hearing impairment.
Subjects were excluded for a personal or family history
of dementia, if they had taken a cognitive assessment within 6
months, or had a history of hearing loss. These subjects took
a battery of cognitive screening tools. Subjects who passed
the screen were then administered the MoCA-H. Group #2
had similar inclusion criteria to Group #1 but also had severeto-profound hearing loss on audiometry. The MoCA-H was
performed on 62 normal hearing subjects and 50 subjects with
HL. The regular MoCA was retested 6 months after MoCA-H was Figure 1. Montreal Cognitive
administered on a subset of Group #1.
Assessment (MoCA)
References
1. http://whqlibdoc.who.int/publications/2012/9789241564458_eng.pdf. “Dementia: a public health priority.” World Health Organization, 2012.
2. Douaud G, et al. “Brain microstructure reveals early abnormalities more than two years prior to clinical progression from mild cognitive impairment to Alzheimer’s disease.” J Neurosci.
2013; 33(5):2147-55.
3. Maioli F, et al. “Conversion of mild cognitive impairment to demential in elderly subjects: A preliminary study in a memory cognitive disorder unit.” Arch Gerontol Geriatr. 2007; 44 Suppl
1:233-41.
Table 1. Comparison of MoCA and MoCA-H
scores by task
Table 2. Comparison of MoCA-H Group #1
and MoCA-H Group #2 scores by task
Discussion
Results confirm a trend showing the MoCA-H is normal in the normal cognitive population. The MoCA-H
is easily administered to patients with hearing impairment. Scoring is similar to the original, validated MoCA
test. Our results show patients with normal hearing performed better on certain testing domains than subjects
with significant hearing impairment. Differences in certain domains are best explained by differences between
the relationship of hearing and short-term memory and the relationship between visualization and short-term
memory neural pathways. Studies have shown that auditory directions are more accurately recalled in the
short term memory setting compared recall based on visual input alone (7). This suggests a possible need for
an “auditory adjustment factor” to requirement normalize scores of the MoCA-H.
MoCA-H
Figure 2. Modified
visuospatial/ executive
task of Modified MoCA
(MoCA-H)
Conclusion
The MoCA-H results of normal cognitively screen subjects have a high correlation to MoCA results.
The MoCA-H is the only tool to detect MCI in patients with hearing impairment. This will lead to early detection
and treatment of MCI in the hearing-impaired elderly.
4. Allan CL, et al. “Early diagnosis beneficial in Alzheimer’s disease.” Practitioner. 2013 Jan; 257 (1757):15-8,2.
5. Nasreddine Z, et al. “The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment.” 2005, JAGS 53:695-699
6. Folstein MF, et al. “”Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician”. Journal of Psychiatric Research 1975; 12 (3): 189–98.
7. Watkins MJ, et al. “Short-term memory for the timing of auditory and visual signals.” J Exp Psycho Learn Mem Cogn. 1992; 18(5):931-7.