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Articles
November 23, 2009
Letter to the Editor

Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease

November 24, 2009 issue
73 (21) 1738-1745

Abstract

Background: Due to the high prevalence of mild cognitive impairment (MCI) and dementia in Parkinson disease (PD), routine cognitive screening is important for the optimal management of patients with PD. The Montreal Cognitive Assessment (MoCA) is more sensitive than the commonly used Mini-Mental State Examination (MMSE) in detecting MCI and dementia in patients without PD, but its validity in PD has not been established.
Methods: A representative sample of 132 patients with PD at 2 movement disorders centers was administered the MoCA, MMSE, and a neuropsychological battery with operationalized criteria for deficits. MCI and PD dementia (PDD) criteria were applied by an investigator blinded to the MoCA and MMSE results. The discriminant validity of the MoCA and MMSE as screening and diagnostic instruments was ascertained.
Results: Approximately one third of the sample met diagnostic criteria for a cognitive disorder (12.9% PDD and 17.4% MCI). Mean (SD) MoCA and MMSE scores were 25.0 (3.8) and 28.1 (2.0). The overall discriminant validity for detection of any cognitive disorder was similar for the MoCA and the MMSE (receiver operating characteristic area under the curve [95% confidence interval]): MoCA (0.79 [0.72, 0.87]) and MMSE (0.76 [0.67, 0.85]), but as a screening instrument the MoCA (optimal cutoff point = 26/27, 64% correctly diagnosed, lack of ceiling effect) was superior to the MMSE (optimal cutoff point = 29/30, 54% correctly diagnosed, presence of ceiling effect).
Conclusions: The Montreal Cognitive Assessment, but not the Mini-Mental State Examination, has adequate psychometric properties as a screening instrument for the detection of mild cognitive impairment or dementia in Parkinson disease. However, a positive screen using either instrument requires additional assessment due to suboptimal specificity at the recommended screening cutoff point.

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Letters to the Editor
6 April 2010
Reply from the authors
Daniel Weintraub, University of Pennsylvania and the Philadelphia Veterans Affairs Medical Center
Andrew D Siderowf (Philadelphia, PA; [email protected]), Sharon X Xie (Philadelphia, PA; [email protected])

We thank Dr. Kasten et al. for their thoughtful comments regarding our research assessing the validity of the MoCA and MMSE for the detection of mild cognitive impairment (PD-MCI) and dementia (PDD) in Parkinson's disease (PD). [1]

We acknowledge that our research addresses the performance of the MoCA and MMSE in PD only and that the results of a clinical research study conducted at two sites cannot be generalized to all PD patients. However, the recommended MoCA cutoff of 27 that we reported for the detection of PD-MCI or PDD is similar to that reported by Nasreddine et al. for the detection of MCI or mild AD. [4]

They used this cutoff in a group with less formal education than ours (cutoff score of 26) and the superior sensitivity of the MoCA relative to the MMSE at the same cutoff score was similar. [4] The recommended cutoff score for MoCA in patients with significantly less formal education is likely lower. Dr. Kasten et al. also highlight that normative data are not currently available for the MoCA.

We disagree that interpretation of our results is complicated by the combined analysis of PD-MCI and PDD. Although sample sizes were relatively small, we present separate results for the two groups and found a slightly lower recommend cutoff point for PDD compared with PD- MCI. Although PPVs and NPVs are affected by the prevalence of the disorder being studied, we understated the PPV and NPV of the instruments in our population. This is because 30% of subjects met criteria for PD-MCI or PDD, and recent epidemiological studies suggest that the combined cross-sectional prevalence of PD-MCI and PDD in clinical populations is probably closer to 40%. [5]

Cognitive screening is important in PD, given the relatively common occurrence of the disease and a projected cumulative incidence of PDD of 80-90%. [6] We put our results in the context of research from other groups suggesting that the MoCA is superior to the MMSE as a cognitive screening instrument in PD. [7,8]

References

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5. Caviness JN, Driver-Dunckley E, Connor DJ, et al. Defining mild cognitive impairment in Parkinson's disease. Mov Disord 2007;22:1272-1277.

6. Buter TC, van den Hout A, Matthews FF, Larsen JP, Brayne C, Aarsland D. Dementia and survival in Parkinson disease: A 12-year population study. Neurology 2008;70:1017-1022.

7. Zadikoff C, Fox SH, Tang-Wai DF, et al. A comparison of the mini mental state exam to the montreal cognitive assessment in identifying cognitive deficits in Parkinson's disease. Mov Disord 2007;23:297-299.

8. Gill DJ, Freshman A, Blender JA, Ravina B. The Montreal Cognitive Assessment as a screening tool for cognitive impairment in Parkinson's disease. Mov Disord 2008;23:1043-1046.

Disclosures: See original article for full disclosure list.

6 April 2010
Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease
Meike Kasten, University of Luebeck
Norbert Bruggemann, Alexander Schmidt, Christine Klein
We read with great interest the article by Hoops et al. who assessed the performance of the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) in Parkinson disease (PD) patients at different cutoffs. [1]

Since their article focuses solely on PD, it is unclear whether the cut-offs are applicable to non-PD subjects, which would be important. [1] We applied the suggested cutoffs (MMSE≥29/MoCA≥26) to a sample of 95 PD patients and 112 controls. The percentages of subjects screening positive for possible cognitive impairment were 57%/53% (MMSE/MoCA) for the PD patients and 50%/32% for the controls. MMSE scores were similar in PD and controls in both total score and subscores, whereas the MoCA scores were lower in PD, particularly for language fluency and visuospatial tests. Both MMSE and MoCA correlated with age (MMSE r=-0.279, MoCA r=-0.422) and the MMSE (r=0.381, p<_0.001 but="but" not="not" the="the" moca="moca" r="0.87," p="p" correlated="correlated" with="with" education="education" years.="years."/>The mean education years reported by Hoops et al. (>16 years) seems high compared to our sample (11.4±3.6 in PD and 11.2±3.1 in controls) and another recent report. [2] The population in Hoops et al.'s study may not be representative of the majority of PD patients and this may affect test results. While highly informative, the listed sensitivity, specificity, and cutoff values [1] raise concerns.

Interpretation is complicated by the combined analysis of mild cognitive impairment and dementia. The presented positive and negative predictive values for MoCA and MMSE are rather low. Furthermore, sensitivity, specificity, and pre-test probability of disease determine the positive predictive value (PPV) and the negative predictive value (NPV). Changing the prevalence of cognitive impairment in the calculation from about 30% in the article 1 to 5%--realistic in controls with a mean age of 70-79 years-- [3] the MoCA yields a PPV of only 9.0% and the MMSE of 7.4%.

Taking the authors' and our results together, we conclude that neither test is sufficient to diagnose cognitive impairment despite superior performance of the MoCA, in particular when the established cutoffs (<_24 for="for" dementia="dementia" are="are" used.="used." furthermore="furthermore" at="at" the="the" suggested="suggested" screening="screening" cutoffs="cutoffs" _1="_1" mmse="mmse" did="did" not="not" differentiate="differentiate" between="between" patients="patients" and="and" controls="controls" both="both" tests="tests" resulted="resulted" in="in" high="high" percentages="percentages" of="of" subjects="subjects" needing="needing" further="further" clarification.="clarification." this="this" calls="calls" into="into" question="question" utility="utility" these="these" different="different" research="research" settings.="settings." p="p"/>References

1. Hoops S, Nazem SS, Siderowf AD. Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease. Neurology 2009;73:1738-1745.

2. Aarsland D, Bronnick K, Larsen JP, Tysnes OB, Alves, G. Cognitive impairment in incident, untreated Parkinson disease: the Norwegian ParkWest study. Neurology 2009;72:1121-1126.

3. Plassman BL, Langac KM,Fisherd GG et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology 2007;29:125-132.

Acknowledgments: This work was supported by EU grant GENEPARK (EU-LSHB-CT-2006-037544), the NGFNplus (Functional Genomics of Parkinson's Disease), the Volkswagen Foundation, the Hermann and Lilly Schilling Foundation, and the Hilde Ulrichs Foundation for Parkinson's Disease Research.

Disclosure: Dr. Kasten received a Junior Travel Award from the Melvin Yahr Foundation to attend the International Parkinson disease congress. Drs. Bruggemann and Schmidt report no disclosures. Prof. Klein serves on the scientific advisory boards of the Bachmann-Strauss Dystonia and Parkinson's Disease Foundation and received honoraria from GSK and Schwarz Pharma.

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Neurology®
Volume 73Number 21November 24, 2009
Pages: 1738-1745
PubMed: 19933974

Publication History

Published online: November 23, 2009
Published in print: November 24, 2009

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Affiliations & Disclosures

S. Hoops, BA
From the Departments of Psychiatry (S.H., S.N., D.W.), Neurology (A.D.S., J.E.D., M.B.S., D.W.), and Biostatistics and Epidemiology (S.X.X.), University of Pennsylvania; and Parkinson’s Disease Research, Education and Clinical Center (J.E.D., M.B.S., D.W.) and Mental Illness Research, Education and Clinical Center (D.W.), Philadelphia VA Medical Center, PA.
S. Nazem, BA
From the Departments of Psychiatry (S.H., S.N., D.W.), Neurology (A.D.S., J.E.D., M.B.S., D.W.), and Biostatistics and Epidemiology (S.X.X.), University of Pennsylvania; and Parkinson’s Disease Research, Education and Clinical Center (J.E.D., M.B.S., D.W.) and Mental Illness Research, Education and Clinical Center (D.W.), Philadelphia VA Medical Center, PA.
A. D. Siderowf, MD
From the Departments of Psychiatry (S.H., S.N., D.W.), Neurology (A.D.S., J.E.D., M.B.S., D.W.), and Biostatistics and Epidemiology (S.X.X.), University of Pennsylvania; and Parkinson’s Disease Research, Education and Clinical Center (J.E.D., M.B.S., D.W.) and Mental Illness Research, Education and Clinical Center (D.W.), Philadelphia VA Medical Center, PA.
J. E. Duda, MD
From the Departments of Psychiatry (S.H., S.N., D.W.), Neurology (A.D.S., J.E.D., M.B.S., D.W.), and Biostatistics and Epidemiology (S.X.X.), University of Pennsylvania; and Parkinson’s Disease Research, Education and Clinical Center (J.E.D., M.B.S., D.W.) and Mental Illness Research, Education and Clinical Center (D.W.), Philadelphia VA Medical Center, PA.
S. X. Xie, PhD
From the Departments of Psychiatry (S.H., S.N., D.W.), Neurology (A.D.S., J.E.D., M.B.S., D.W.), and Biostatistics and Epidemiology (S.X.X.), University of Pennsylvania; and Parkinson’s Disease Research, Education and Clinical Center (J.E.D., M.B.S., D.W.) and Mental Illness Research, Education and Clinical Center (D.W.), Philadelphia VA Medical Center, PA.
M. B. Stern, MD
From the Departments of Psychiatry (S.H., S.N., D.W.), Neurology (A.D.S., J.E.D., M.B.S., D.W.), and Biostatistics and Epidemiology (S.X.X.), University of Pennsylvania; and Parkinson’s Disease Research, Education and Clinical Center (J.E.D., M.B.S., D.W.) and Mental Illness Research, Education and Clinical Center (D.W.), Philadelphia VA Medical Center, PA.
D. Weintraub, MD
From the Departments of Psychiatry (S.H., S.N., D.W.), Neurology (A.D.S., J.E.D., M.B.S., D.W.), and Biostatistics and Epidemiology (S.X.X.), University of Pennsylvania; and Parkinson’s Disease Research, Education and Clinical Center (J.E.D., M.B.S., D.W.) and Mental Illness Research, Education and Clinical Center (D.W.), Philadelphia VA Medical Center, PA.

Notes

Address correspondence and reprint requests to Dr. Daniel Weintraub, 3615 Chestnut St., Room 330, Philadelphia, PA 19104-2676 [email protected]

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