Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease
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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REFERENCES
1.
Aarsland D, Andersen K, Larsen JP, Lolk A, Kragh-Sørensen P. Prevalence and characteristics of dementia in Parkinson disease: an 8-year prospective study. Arch Neurol 2003;60:387–392.
2.
Muslimovic D, Post B, Speelman JD, Schmand B. Cognitive profile of patients with newly diagnosed Parkinson disease. Neurology 2005;65:1239–1245.
3.
Caviness JN, Driver-Dunckley E, Connor DJ, et al. Defining mild cognitive impairment in Parkinson’s disease. Mov Disord 2007;22:1272–1277.
4.
Williams-Gray CH, Foltynie T, Brayne CEG, Robbins TW, Barker RA. Evolution of cognitive dysfunction in an incident Parkinson’s disease cohort. Brain 2007;130:1787–1798.
5.
Foltynie T, Brayne CEG, Robbins TW, Barker RA. The cognitive ability of an incident cohort of Parkinson’s patients in the UK: The CamPaIGN study. Brain 2004;127:550–560.
6.
Aarsland D, Bronnick K, Larsen JP, Tysnes OB, Alves G, for the ParkWest Study Group. Cognitive impairment in incident, untreated Parkinson disease: The Norwegian ParkWest Study. Neurology 2009;72:1121–1126.
7.
Janvin CC, Larsen JP, Aarsland D, Hugdahl K. Subtypes of mild cognitive impairment in Parkinson’s disease: progression to dementia. Mov Disord 2006;21:1343–1349.
8.
Marras C, McDermott MP, Rochon PA, Tanner CM. Predictors of deterioration in health-related quality of life in Parkinson’s disease: results from the DATATOP trial. Mov Disord 2008;23:653–659.
9.
Martin RC, Okonkwo OC, Hill J, et al. Medical decision-making capacity in cognitively impaired Parkinson’s disease patients without dementia. Mov Disord 2008;23:1867–1874.
10.
Athey RJ, Porter RW, Walker RW. Cognitive assessment of a representative community population with Parkinson’s disease (PD) using the Cambridge Cognitive Assessment–Revised (CAMCOG-R). Age Ageing 2005;34:268–273.
11.
Kalbe E, Calabrese P, Kohn N, et al. Screening for cognitive deficits in Parkinson’s disease with the Parkinson neuropsychometric dementia assessment (PANDA) instrument. Parkinsonism Relat Disord 2008;14:93–101.
12.
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.
13.
Nazem S, Siderowf A, Duda JE, et al. Montreal Cognitive Assessment (MoCA) performance in Parkinson’s disease patients with “normal” global cognition by Mini-Mental State Examination score. J Am Geriatr Soc 2009;57:304–308.
14.
Hobson P, Meara J. The detection of dementia and cognitive impairment in a community population of elderly people with Parkinson’s disease by use of the CAMCOG neuropsychological test. Age Ageing 1999;28:39–43.
15.
Starkstein SE, Merello M. The Unified Parkinson’s Disease Rating Scale: validation study of the mentation, behavior, and mood section. Mov Disord 2007;22:2156–2161.
16.
Dubois B, Burn D, Goetz C, et al. Diagnostic procedures for Parkinson’s disease dementia: recommendations for the Movement Disorder Society Task Force. Mov Disord 2007;16:2314–2324.
17.
Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53:695–699.
18.
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.
19.
Gelb DJ, Oliver E, Gilman S. Diagnostic criteria for Parkinson’s disease. Arch Neurol 1999;56:33–39.
20.
Brandt J, Benedict RHB. The Hopkins Verbal Learning Test–Revised. Odessa, FL: Psychological Assessment Resources; 2001.
21.
Culbertson WC, Zillmer EA. Tower of London-Drexel (TOLDX), Technical Manual. 2nd edition ed. North Tonawanda, NY: Multi-Health Systems; 2005.
22.
Golden C. The Stroop Color and Word Test. Wood Dale, IL: Stoelting Company; 1994.
23.
Gladsjo JA, Shuman CC, Evans JD, Peavy GM, Miller SW, Heaton RK. Norms for letter and category fluency: demographic corrections for age, education, and ethnicity. Assessment 1999;6:147–178.
24.
Lezak MD, Howieson DB, Loring DW. Neuropsychological Assessment. 4th ed. New York: Oxford University Press; 2004.
25.
Storey JE, Rowand JTJ, Conforti DA, Dickson HG. The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale. Int Psychogeriatr 2004;16:13–31.
26.
Emre M, Aarsland D, Brown R, et al. Clinical diagnostic criteria for dementia associated with Parkinson’s disease. Mov Disord 2007;22:1689–1707.
27.
Petersen RC, Doody R, Kurz A, et al. Current concepts in mild cognitive impairment. Arch Neurol 2001;58:1985–1992.
28.
Winblad B, Palmer K, Kivipelto M, et al. Mild cognitive impairment: beyond controversies, towards a consensus: report of the International Working Group on Mild Cognitive Impairment. J Intern Med 2004;256:240–246.
29.
Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. In: Brink TL, ed. Clinical Gerontology: A Guide to Assessment and Intervention. New York: The Haworth Press; 1986:165–173.
30.
Fahn S, Elton RL, the UPDRS Development Committee. Unified Parkinson’s Disease Rating Scale. In: Fahn S, Marsden CD, Calne D, Goldstein M, eds. Recent Developments in Parkinson’s Disease. Florham Park, NJ: Macmillan Health Care Information; 1987:153–163.
31.
Mitchell AJ. A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment. J Psychiatr Res 2009;43:411–431.
32.
SPSS for Windows version 15.0. Chicago: SPSS Inc.; 2007.
33.
Bossuyt PM, Reitsma JB, Bruns DE, et al. Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD Initiative. Ann Intern Med 2003;138:40–44.
34.
Riedel O, Klotsche J, Spottke A, et al. Cognitive impairment in 873 patients with idiopathic Parkinson’s disease: results from the German Study on Epidemiology of Parkinson’s Disease with Dementia (GEPAD). J Neurol 2008;255:255–264.
35.
McHorney CA, Tarlov AR. Individual-patient monitoring in clinical practice: are available health status surveys adequate? Qual Life Res 1995;4:293–307.
36.
Mattis S. Dementia Rating Scale: Professional Manual. Odessa, FL: Psychological Assessment Resources; 1988.
37.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, rev. Washington, DC: American Psychiatric Association; 2000.
38.
Kulisevsky J, Pagonabarraga J. Cognitive impairment in Parkinson’s disease: tools for assessment and diagnosis. Mov Disord 2009;24:1103–1110.
39.
Pagonabarraga J, Kulisevsky J, Llebaria G, García-Sánchez C, Pascual-Sedano B, Gironell A. Parkinson’s disease-cognitive rating scale: a new cognitive scale specific for Parkinson’s disease. Mov Disord 2008;23:998–1005.
40.
O’Bryant SE, Humphreys JD, Smith GE IR, Graff-Radford NR, Petersen RC, Lucas JA. Detecting dementia with the Mini-Mental State Examination in highly educated individuals. Arch Neurol 2008;65:963–967.
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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.
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
4. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005;53:695-699.
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.