British Journal of
Learning Disabilities
The Official Journal of the British Institute of Learning Disabilities
ORIGINAL ARTICLE
The utility of the Montreal
Cognitive Assessment as a
mental capacity assessment
tool for patients with a
learning disability
Daniel Edge, Adenekan Oyefeso, Carys Evans and Amber Evans, Department of Psychology
and Therapies, Jeesal Cawston Park, Alysham Road, Norfolk, NR10 4JD, UK
(E-mail: [email protected])
Received 3 July 2014; Accepted 28 October 2015
Accessible summary
• Accurate assessment of a patient’s mental capacity is important, yet out of the
•
•
Abstract
clinical assessments currently available, there does not appear to be sufficient
accessible tools suitable for people with a learning disability.
Incorrect assumptions are often made regarding the capacity of patients who have
learning disabilities to make decisions about important aspects of their life.
This preliminary study investigated whether or not it was possible to adapt a
well-known assessment of cognitive impairment (The Montreal Cognitive
Assessment) and use this as a tool to determine capacity in patients with a
learning disability.
Objective: To determine the psychometric properties of the Montreal Cognitive
Assessment (MoCA) in patients with a learning disability and examine it’s utility for
conducting mental capacity assessment.
Method: This study was a cross-sectional, instrument validation study in an
inpatient hospital setting, located in the East of England. The sample consisted of
two groups: (i) 31 consecutively admitted hospital patients and (ii) 10 multidisciplinary team members who served as a comparison group. The MoCA, a 12-item
screen for mild cognitive impairment and the Dysexecutive Questionnaire (DEX),
were used in this study. Item analysis was conducted by comparing item
endorsement for all participants that had a learning disability utilising Difficulty
and Discrimination Indices for each item on the MoCA. We examined the internal
consistency of a revised scale derived from item analysis and used a one-way
ANOVA to determine concurrent validity by comparing scores between two patient
subgroups and the comparison group.
Results: A 7-item scale, ‘MoCA-LD’ (alpha coefficient = 0.82) emerged from item
analysis. A statistically significant negative correlation was observed between
MoCA-LD and DEX (Pearson correlation = 0.66, P < 0.01). As expected, participants in the borderline category scored higher on MoCA-LD than those with mild
learning disability, as did those with no learning disability (P < 0.001).
ª 2015 John Wiley & Sons Ltd, British Journal of Learning Disabilities
doi:10.1111/bld.12157
2
D. J. Edge, et al.
Conclusion: The MoCA-LD has the potential to be a useful tool for mental capacity
assessment in patients with a learning disability.
Keywords
Assessment, DEX, learning disability, mental capacity, MoCA
Introduction
The Mental Capacity Act, introduced in the United Kingdom in 2005, states that a person is not capable of making a
decision for themselves if they are deemed unable to:
‘understand the information relevant to the decision, retain that
information, use or weigh that information as part of the process of
making the decision or communicate [their] decision’ (Mental
Capacity Act, 2005, part 1, page 2). The question of a
person’s capacity to make important decisions is a common
one amongst mental health professionals. Not only is the
question common, it is also extremely important. The
answer to such a question could potentially render a patient
helpless in making decisions regarding their treatment, care,
finances and many other important aspects of their life.
Accurate and valid assessment of a patient’s mental capacity is, therefore, essential for ensuring that practitioners
comply with the requirements defined in the Mental
Capacity Act (2005) so that important decisions are always
made with the patient’s involvement where they are
capable. In clinical practice, knowledge deficits about the
assessment of decision making capacity are common.
Ganzini et al., (2003) reviewed 395 responses from different
healthcare professionals where 22 of 23 pitfalls were
identified as ‘common’ with the vast majority being rated
as somewhat important to patient care.
A learning disability is considered to be a life-long
developmental condition that comprises of significant
impairments in both a person’s intellectual functioning
and their adaptive/social functioning (The British Psychological Society, 2000). The term used to describe this
condition can vary in different countries e.g., in the United
States, the term ‘intellectual disability’ is used instead of
learning disability. Amongst adults with learning disabilities there is a high rate of mental incapacity, particularly
with regard to making important healthcare decisions
(Wong et al., 2000). This differs from studies examining
capacity amongst general psychiatric in-patients where a
sizeable proportion is found to be capable of making
treatment decisions (Okai et al., 2007). However, it is still
not appropriate to readily assume that all people with a
learning disability necessarily lack decision making capacity
and incorrect assumptions are often made regarding incapacity when treating these individuals (Bradbury-Jones
et al., 2013).
Since the introduction of the Mental Capacity Act (2005)
in the United Kingdom, there has been a need for the
development of valid and reliable measures of decision
making ability that reflect the legal criteria for mental
capacity (Keywood & Flynn, 2006; Moye et al., 2006). A
comprehensive assessment of capacity requires time and
has been described as cumbersome and difficult to perform
in an acute care setting (Chow et al., 2010). A recent
integrative review of mental capacity assessment tools
identified 19 instruments currently available to clinicians
to help assess an individual’s capacity to consent to
treatment. The instruments tend to involve some form of
semi structured/structured interview and can take between
10 and 90 min to administer. The majority were standardised against in-patient populations with conditions such as
dementia or schizophrenia and only a small number were
found to have demonstrated both reliability and validity
(Lamont et al., 2013). As such, the current available range of
mental capacity assessment tools is not ideally suited for
patients with learning disabilities. It has, therefore become
necessary to develop an instrument for assessing mental
capacity which reflects the needs of this distinct population.
In particular, such a tool should ideally be quick to
administer, and be flexibly presented in a way that the
respondent is able to understand to ensure that individuals
are given every opportunity to demonstrate their capacity
for decision making (Bailey et al., 2011).
One of the difficulties identified with assessing the mental
capacity of someone with a learning disability is being able
to accurately evaluate their ability to ‘weigh up’ the
information relevant to their decision (Willner et al.,
2010b). Studies investigating capacity for financial reasoning
in patients with learning disabilities suggest that the ability
to perform consistently on decision making tasks is more
strongly related to executive functioning (EF) than Intelligence Quotient (IQ). In addition, it is thought that EF is
closely related to the ability to ‘weigh up’ information
relevant to a decision (Willner et al., 2010a; Willner et al.,
2010b; Suto et al., 2005). It is important, therefore, that
capacity assessment in a learning disability population
includes an assessment of EF to reflect the legal criteria for
assessing mental capacity.
We proposed to adapt a cognitive screening assessment
to act as a mental capacity screening assessment tool for
people with a learning disability. The Montreal Cognitive
Assessment (MoCA): (Nasreddine et al., 2005) is a 10-min,
30-point cognitive screening test designed to assist health
professionals in the detection of Mild Cognitive Impairments (MCI) in adults. It consists of 12 items and is an
ª 2015 John Wiley & Sons Ltd, British Journal of Learning Disabilities
Learning disability mental capacity assessment
assessment which is widely used in clinical settings. To
date, the majority of research regarding the application of
the MoCA involves tests of specificity and validity regarding the detection of MCI and conditions such as Alzheimer’s disease. Within specific populations (e.g. memory
clinics, people aged over 60) the MoCA has been found to
have high sensitivity in identifying MCI and dementia
(Smith et al., 2007). The MoCA was chosen for this study as
it is currently used as part of routine clinical assessment at
the study location and patients have generally responded
well to it. It is easy to use and measures a wide range of
cognitive functions related to mental capacity. This is also
reflected in a survey of different cognitive screening
assessments which suggests that the MoCA is regarded
by relevant professionals as easy to administer, effective
and well-tolerated by those completing it (Zahinoor et al.,
2013). Some studies exploring the use of the MoCA as a
screening tool for cognitive impairments in schizophrenic
patients have reported preliminary evidence that the MoCA
performs well in detecting true positive findings (Flsekovic
et al., 2012).
The MoCA has a strong correlation with the Mini Mental
State Examination (MMSE): (Flsekovic et al., 2012) and those
judged to lack capacity are more likely to have cognitive
impairments on the MMSE (Raymont et al., 2007). This
suggests that the MoCA is likely to have a similar relationship with existing capacity assessment tools. Currently,
there is no evidence to suggest that these items are
internally consistent within a learning disability population
nor is there evidence that the test has been modified for
different patient populations, other than changing the
language in which it is presented. The original MoCA was
designed to detect MCI. In a learning disability population,
where cognitive impairment is generally more severe, there
is a high possibility that the scale in its current form will
have a ceiling effect due to a lack of item endorsement. It is
likely, therefore, that some items in the MoCA are redundant in a learning disability population.
Overall, the aims of this study are:
1. To explore the relationship between the MoCA and an
individual’s executive functioning using the Dysexecutive Questionnaire (DEX).
2. To establish whether or not the MoCA can be used as
screening tool for assessing mental capacity for patients
with a learning disability
Method
Participants
This study was conducted at a 53 bed, independent hospital
located in the East of England. The hospital is registered
with the Care Quality Commission, for people with a
learning disability who may also have a comorbid mental
ª 2015 John Wiley & Sons Ltd, British Journal of Learning Disabilities
3
health problem, personality disorder, forensic history or
Autistic Spectrum Disorder. Anonymised MoCA data from
a sample of 31 consecutively admitted patients at the study
location were analysed. All patient participants had either
been detained under the Mental Health Act (2007) or had
given consent to be assessed and to receive treatment
informally for the duration of their stay at the hospital. The
majority of the patients included in our analysis were men
(64.5%) and aged between 18 and 57 years (Mean = 34.9,
SD = 12.6). The patient’s data showed varying levels of
intellectual functioning as well as a range of diagnoses. The
majority (61.3%) had a mild learning disability. Other
learning disability ranges were borderline (19.4%), and
moderate (3.2%). Other patients (16.1%) who had normal
intellectual functioning with an autistic spectrum disorder
were excluded from our analysis leaving a total of 26 data
records in the patient group.
A second group of 10 members from the multi-disciplinary team at the study location volunteered to provide
MoCA data as a comparison group. As each person was a
professional working at the hospital it was assumed that
they were free of mental illness, did not have a learning
disability and had decision making capacity. This group
consisted of two males and eight females aged between 22
and 60 (Mean = 40.5, SD = 14.4).
While the comparison group was not completely matched
to the patient group, there was a substantial overlap in age
distribution of both groups, thus reducing any age related
bias in cognitive functioning measured by the MoCA. A
T-test showed that the mean difference in age between the
two groups was not significant (P = 0.29).
Materials
In addition to the MoCA, this study also used routinely
collected data from the DEX to evaluate the MoCA’s ability
to measure executive functioning. The DEX is a 20-item,
three factor questionnaire designed to assess everyday
changes to cognition, emotion and behaviour after neuropathology. Each item on the DEX gives a statement
related to a characteristic of Dysexecutive Syndrome and is
scored on a 5 point (0–4) Likert scale (ranging from ‘Never’
to ‘Very often’). The DEX comes in two versions, one of
which is designed to be completed by the subject (DEX-S)
and the other by a relative or carer (DEX-I). The only
difference between the two versions is that DEX-S is written
in the first person (i.e. ‘I have difficulty thinking ahead and
planning for the future’) and DEX-I is written in the third
person (i.e ‘Has difficulty thinking ahead and planning for the
future’) Both versions are commonly used as part of the
Behavioural Assessment of the Dysexecutive Syndrome
(BADS) which is considered an ecologically valid multidimensional measure of executive functioning (Barker et al.,
2011). DEX-I ratings are considered a more reliable index
4
D. J. Edge, et al.
due to the tendency for patients to rate themselves with
fewer or less problems (McBrinn et al., 2008). The DEX- I has
also been found to accurately identify ‘real world’ executive
deficits and these measures corresponded with subsequent
performance on BADS executive subtests (Wilson, 1996;.
cited in Barker et al., 2011).
Procedure
MoCA administration to patients was part of routine clinical
assessment following admission to the hospital. Each
individual in the patient group was administered the
MoCA (English Additional Version 3) by a professional
using the guidance notes provided by the authors. All
assessments were completed in one sitting at a location
which was private and familiar to the individual being
tested. The nonpatient comparison group were administered the MoCA in the same way as the patient group. DEXI questionnaires were completed on behalf of the patient
group by clinical staff members of the hospital who had
primary responsibilities for each patient and had interacted
with the patient continuously for at least 2 weeks following
admission. In most cases, it was the patient’s primary nurse
who completed the questionnaire, but keyworkers were also
used from the support team where the primary nurse was
not available. DEX-S questionnaires were completed by the
comparison group.
Ethical issues
According to the NHS England Health Research Authority
(HRA) decision tool, this study does not require ethics
approval. Staff participants provided informed consent and
the hospital’s Clinical Effectiveness, Audit and Research
Committee approved the study. All data records were
anonymised.
1972). A second analysis using Pearson’s Correlation
coefficient (one-tailed) was used to examine the relationship between DEX scores and the revised instrument. A
one-way Analysis of Variance (ANOVA) was used to
determine concurrent validity of the revised scale by
comparing the mean scores between the comparison group
and those in the borderline and mild intellectual range. As
there was only one patient identified with a moderate
learning disability, their data were not included in this
part of the analysis.
Results
Alpha coefficient for the MoCA and the DEX in the patient
group were 0.78 and 0.88, respectively, with a significant
negative correlation between both instruments (r = 0.70,
P < 0.01). Item analysis using difficulty and discrimination
indices identified seven items that were appropriate for the
patient group, having sufficiently discriminated between
the highest and lowest performing patients (Table 1). The
revised scale, termed ‘MoCA-LD’ for convenience, consisted
of the following tasks: Clock Drawing, Trail Making, Copy
Cylinder, Working Memory, Naming, Digit Span and
Orientation. The scale had a high internal consistency
(alpha coefficient = 0.82) and maintained a significant negative correlation with the DEX for all participants
(r = 0.66, P < 0.01) (Fig. 1).
The means and standard deviations for each of the three
groups is given in Table 2. Due to the nonequivalence in
variance between the three groups, the Welch’s F ratio was
used for comparing the mean differences in MoCA-LD scores.
There was a significant difference in MoCA-LD scores
between the comparison group and those in the borderline
and mild disability ranges (Welch’s F (2, 12.23) = 36.81,
P < 0.001) (Table 3). Post hoc tests (Games-Howell) showed
statistically significant mean differences between all three
groups (Table 4).
Data analysis
The SPSS version 20 (SPSS IBM, New York, U.S.A, 2011) was
used for data analysis. Pearson’s Correlation coefficient was
used to test the correlation between DEX and MoCA patient
scores. Alpha coefficient was conducted on MoCA scores to
determine internal consistency reliability.
Item analysis for the MoCA was conducted by calculating Difficulty and Discriminatory Indices for each item
based on the data from all participants who had a learning
disability. Items were selected for a revised scale if the
Difficulty Index did not exceed the calculated optimal level
of the item and the Discrimination Index exceeded the
calculated lower bound for the item. This would suggest
that the item was neither too easy nor too difficult to
discriminate between the highest and lowest performers of
the patient group (Crocker & Algina, 1986; Nunnally,
Discussion
In this preliminary study, we have been able to extract a
modified MoCA-LD scale with a high internal consistency
which can assess cognitive skills reflective of the legal
criteria to determine a person’s mental capacity. For
example, the digit span task and working memory task
measure a patient’s ability to retain information. In
addition to the individual tasks eliciting information
about a patient’s ability to communicate and understand
information the significant correlation between the MoCALD scale and the DEX questionnaire indicates that a
person who obtains a low score on the MoCA-LD is more
likely to have executive dysfunction than someone who
obtains a high score. As suggested by Willner et al.,
(2010a,b), executive dysfunction appears to be a key factor
ª 2015 John Wiley & Sons Ltd, British Journal of Learning Disabilities
Learning disability mental capacity assessment
5
Table 1 Items analysis for the MoCA
MoCA item
Difficulty
index (p)
Discrimination
index (d)
Optimal
level
Lower
bound
Corrected item
total correlation
Clock Drawinga
Trail Makinga
Copy Cylindera
Naminga
Working Memorya
Tapping
Digit Spana
Serial Subtraction
Repetition
Fluency
Abstraciton
Orientationa
0.23
0.5
0.42
0.58
0.12
0.62
0.23
0.27
0.12
0.12
0.31
0.54
0.5
0.75
0.88
0.62
0.38
0.38
0.5
0.38
0
0
0.38
0.88
0.62
0.75
0.75
0.62
0.58
0.75
0.66
0.62
0.66
0.75
0.66
0.57
0.39
0.66
0.66
0.39
0.29
0.66
0.49
0.39
0.49
0.66
0.49
0.26
0.72
0.62
0.74
0.62
0.63
–
0.63
–
–
–
–
0.67
Identified MOCA-LD Items where p < Optimal Level AND d > Lower Bound.
a
Table 4 Post hoc analysis of mean difference (Games-Howell)
Mean difference
Groups
Comparison
Borderline
Borderline
3.23
–
*
Mild
9.74***
6.51**
P < 0.05.
P < 0.005.
***
P < 0.001.
*
**
Figure 1 MoCA-LD and DEX correlation.
Table 2 Mean and standard deviation of MoCA-LD scores
Group
N
Mean
SD
Comparison
Borderline
Mild
Total
10
6
19
35
19.90
16.67
10.16
14.06
0.99
2.42
4.82
5.76
Table 3 One way ANOVA statistics
Between Groups
Within Groups
Total
Sum of
squares
df
671.13
456.76
1127.89
2
12.23
14.23
Mean
square
Welch’s F
Sig.
335.56
14.27
36.81
–
.0001
ª 2015 John Wiley & Sons Ltd, British Journal of Learning Disabilities
in helping to determine whether an individual can ‘weigh
up’ information; this construct is currently considered to
be difficult to assess for people with a learning disability.
It may also be possible for individual tasks, such as the
working memory task or the naming task, to be adapted
to contain information relevant to the decision being
made.
Total scores on the MoCA-LD scale were also able to
differentiate between individuals in the borderline and mild
IQ range as well as those who had no learning disability. .
The need to conduct mental capacity assessment regularly
is, therefore, indicated to avoid the error of wrong assumption of lack of capacity. The use of a tool such as the MoCALD can help clinicians to extract more detailed information
regarding an individual’s ability to weigh up and retain
information presented to them thus allowing for more
accurate assessment of an individual’s mental capacity
alongside existing methods. At this time, a tool like this may
only be used to indicate the presence of decision making
capacity, but not to confirm its absence. Further work is
required to determine the sensitivity and specificity of the
revised scale in other learning disability settings, e.g., the
community. Overall, the results of this study demonstrate
the potential for the application of the MoCA as a tool for
mental capacity assessment for patients with a learning
disability.
6
D. J. Edge, et al.
Limitations
There are certain limitations worth mentioning when
discussing the results of this study. First, participants in
the patient group were not individually assessed to obtain
their IQ scores. Rather, their admission diagnosis was used
for severity classification of learning disability. Whilst one
can assume that such data are accurate; this information
was not confirmed via a recent or up to date assessment for
all participants in the study. Only a small portion of the
participants had recent diagnoses of a learning disability as
part of the assessment process during their admission to the
hospital. Given that indices of intellectual functioning are
not known to fluctuate easily, it is unlikely that this
limitation will affect the validity of the study findings.
Secondly, the level of co-morbidity within the patient
group was also very high with 26 patient records (84%)
showing a diagnosed mental illness, personality or other
developmental disorders (such as autistic spectrum disorders). Even though a person with learning disabilities
who comes into contact with specialist health services
would often have secondary complex health or personality problems (Tajuddin et al., 2004; Hall et al., 2006), such
problems could be considered confounding factors when
assessing the difference between a person’s mental
capacity and executive functioning. Whilst the high level
of co-morbidity revealed in the patient records may be
reflective of general learning disability populations, the
comparison group entirely consisted of professionals and,
therefore, may not be considered as representative of the
general population. Another limitation of the study is the
relatively small number of records included in data
analysis and the limited population from which the data
were extracted.
Conclusions
The results of this study indicate that it would be beneficial
for future research to gather further data from a range of
populations to establish norms for the use of the MoCA in a
learning disability population using MoCA-LD. Future
research can also aim to expand the general applications
of this preliminary study by including larger sample sizes
taken from a wider variety of services in different settings
nationwide. In addition, further studies exploring the
relationship between the identified MoCA-LD items and
already established capacity assessment tools could potentially lead to the development of the MoCA-LD as a tool for
providing evidence of the presence of decision making
capacity.
When offering treatment to people whose attention and
concentration are often impaired, current mental capacity
assessment tools are time consuming and difficult to
administer. This could lead to clinicians erroneously deem-
ing a person with learning disabilities to lack capacity when
in fact there is no evidence to support this decision; wrong
decisions of this nature can have serious personal and legal
implications (Bradbury-Jones et al., 2013). Development of
specialist tools for assessing mental capacity in learning
disability patient settings is, therefore, of high importance.
Scales such as the MoCA-LD have the potential to meet this
need and help ensure a patient’s right to make decisions in
acute settings is not disregarded.
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