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Screening for mild cognitive impairment in patients with heart failure:

Montreal Cognitive Assessment versus Mini Mental State Exam

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 European Journal of Cardiovascular Nursing
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Screening for mild cognitive impairment in patients with heart failure: Montreal Cognitive Assessment
versus Mini Mental State Exam
Jan Cameron, Linda Worrall-Carter, Karen Page, Simon Stewart and Chantal F Ski
Eur J Cardiovasc Nurs published online 18 April 2012
DOI: 10.1177/1474515111435606

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435606
2012
CNU0010.1177/1474515111435606Cameron et al.European Journal of Cardiovascular Nursing

EUROPEAN
SOCIETY OF
Original Article CARDIOLOGY ®

European Journal of Cardiovascular Nursing

Screening for mild cognitive impairment 0(0) 1­–9

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DOI: 10.1177/1474515111435606

Cognitive Assessment versus Mini cnu.sagepub.com

Mental State Exam

Jan Cameron,1 Linda Worrall-Carter,2 Karen Page,3

Simon Stewart Baker4 and Chantal F Ski2

Abstract
Background: Cognitive impairments occur frequently in patients with chronic heart failure (CHF), resulting in worse
health outcomes than expected.These impairments can remain undetected unless specifically screened.There are limited
sensitive screening measures available in nursing practice to identify mild cognitive impairment (MCI).
Aim: To compare the Montreal Cognitive Assessment (MoCA) with the Mini Mental State Exam (MMSE) in screening
for MCI in CHF patients.
Methods: The MMSE and MoCA were administered to 93 hospitalized CHF patients (70±11 years), without a history of
neurocognitive problems. Patients with low MoCA scores (<26) were compared to those with low MMSE scores (<27).
Two different parameters were examined between the MoCA and the MMSE: level of MCI agreement (Kappa coefficient)
and task errors on assessed cognitive domains (χ2 test).
Results: Statistically more patients had low MoCA scores compared with low MMSE scores (66 vs. 30, p=0.02). The
MoCA classified 38 (41%) patients as cognitively impaired that were not classified by the MMSE. A significantly low level
of agreement was found (κ=0.25, p=0.001) between the MMSE and MoCA in identifying patients with scores suggestive
of MCI. More task errors were observed on the MoCA cognitive domains compared with the MMSE cognitive domains.
In 68% of patients with low cognitive scores, visuospatial task errors were observed on tasks from the MoCA compared
with 22% on a similar task of the MMSE.
Conclusion: The MoCA, a screening tool for MCI, identified subtle but potentially clinically relevant cognitive dysfunctions
with greater frequency than MMSE.

Keywords
Chronic heart failure, cognitive impairment, screening tools, MMSE, Montreal Cognitive Assessment

Introduction experienced by CHF patients can be construed to be a

Chronic heart failure (CHF) is a significant human1–3 and
economic4 burden. To add to the adversity of CHF, patients
have 62% increased odds of developing impaired cognitive
function compared with non-CHF counterparts (OR 1.62,
95% CI 1.48–1.79, p<0.0001).5 Furthermore, this comor-
bidity appears to contribute to worse health outcomes:
premature mortality;6,7 increased hospital admissions;8
feature of mild cognitive impairment (MCI) rather than
dementia. Mild cognitive impairment is considered a tran-
sitional period between normal ageing and the development
of moderate cognitive impairments meeting the diagnosis
1VECCI Building, East Melbourne, Australia
2AustralianCatholic University, Melbourne Australia
3Heart Foundation, Melbourne Australia

inadequate self-care;9 and poor quality of life.10 Interestingly 4IDI Heart and Diabetes Institute, Melbourne Australia

in CHF patients, the clinical features of cognitive impair-

Corresponding author:
ment do not fulfil the criteria for dementia.11 Dr Jan Cameron, VECCI Building, Level 4, 486, Albert Street,
As evident from studies including CHF patients residing East Melbourne, 3002 Australia.
independently in the community,12 cognitive impairments Email: jan.cameron@acu.edu.au

Downloaded from cnu.sagepub.com at Monash University on April 23, 2012

2 European Journal of Cardiovascular Nursing 0(0)
of Alzheimer disease.13 Recently, vascular cognitive
impairment has been introduced to capture the broad spec-
trum of cognitive disorders associated with all forms of cer-
ebral vascular brain injury ranging from MCI through to
dementia.14 Within this classification, four subtypes of vas-
cular MCI are identified: amnestic; amnestic and other
domains; non-amnestic single domain; and non-amnestic
multiple domains. Classification of vascular MCI is based
on the assumption of a decline in cognitive function from a
prior baseline and evidence of impairment in at least one
cognitive domain.14
Neurocognitive testing performed by a mental health
clinician is considered the gold standard for evaluation and
diagnosis of brain pathologies. Protocols have recently
been developed ranging from 5-minute to comprehensive
60-minute assessments15 which have yet to be tested and
implemented in the CHF arena. Prolonged neurocognitive
assessments are not always practical or feasible in the clini-
cal setting.16 Reasons are many and varied, primarily:
•• few clinical nurses are trained to administer neuro-
cognitive tests;
•• tests can be burdensome and require a quiet environ-
ment for administration.
Each of the above adds to the problematic nature of provid-
ing a comprehensive and efficacious assessment of MCI
in the long-term management of patients with CHF.17
Screening for MCI is therefore important in identifying
patients that warrant further neurocognitive investigation.
A variety of comprehensive screening tools have been
developed and extensively used in ruling out dementia.18
When screening for MCI at least four cognitive domains
should be assessed: executive functioning/attention, mem-
ory, language, and visuospatial.14 On this premise, there is
a dearth of screening tools that have been adequately tested
and validated to identify MCI, especially in the CHF popu-
lation. The Mini Mental State Exam (MMSE)19 is one of
the most extensively used dementia screening tools in pri-
mary health care18 and studies assessing cognitive impair-
ment in CHF patients. However, the sensitivity and
specificity of the MMSE is not ideal in MCI screening.20
The Montreal Cognitive Assessment (MoCA)17 is gaining
increased popularity because it was specifically developed
in screening for MCI. However, greater research is required
to validate the MoCA screening instrument especially in
specific cardiac populations.21 The purpose of this study
was to examine differences between the MMSE and MoCA
in screening for MCI among patients with CHF.
Aims and objectives
This study aimed to compare two instruments used by
nurses to screen for MCI in patients with CHF: the MMSE19
and MoCA.17
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The hypotheses were:
1. based on previous research,22,23 more than 30% of
this select sample of CHF patients will have evi-
dence of low cognitive scores (<27 on MMSE and
<26 on MoCA);
2. the two screening methods (MMSE and MoCA)
will differ in the level of agreement in identifying
cognitive impairments suggestive of MCI.
Design and methods
This research was subanalysis of a cross-sectional observa-
tional study that tested a conceptual model of factors that
predicted patient CHF self-care.9
Study sample
Patients were referred from a CHF management programme
at two metropolitan health networks in Victoria, Australia.
Between April 2007 and September 2008, hospital CHF
case managers screened patients for study eligibility.
Subjects who met the inclusion criteria were approached by
the CHF case manager to participate in the study and then
referred to the researcher.
Inclusion/exclusion criteria
The inclusion criteria for the study were: age over 45 years
with a diagnosis of CHF in accordance with the clinical
criteria from Australian Best Practice Guidelines.24 As
such, eligible patients were admitted to the hospital sites
with clinical signs and symptoms of CHF which was fur-
ther supported by objective evidence of cardiac dysfunction
recorded on an echocardiogram.24 Patients were excluded
from the study on the following basis: neurocognitive prob-
lems documented in the medical history (cerebral vascular
accident, transitional ischemic attack, short-term memory
loss, confusion, delirium, or dementia); residing in a resi-
dential nursing home; and inability to answer question-
naires independently due to language barriers or visual
acuity.
Recruitment
A total of 476 six patients admitted with a provisional diag-
nosis of CHF were screened; of those 206 (43%) did not
have a confirmed diagnosis of CHF (Figure 1). From the
270 patients who were eligible, 169 (63%) were excluded.
Reasons for exclusion were: 52 (19%) did not have English
as their primary language, 56 (21%) had a history of neuro-
cognitive events, 14 (5%) had poor visual/hearing acuity
that was identified as a barrier to completing questionnaires
independently, seven (3%) were in the terminal phase of
Cameron et al. 3
476
paents screened
270 eligible
(CHF diagnosis confirmed)
131 Met the study inclusion
criteria
30 declined
101 Recruited
8 withdrew
Sample = 93
Figure 1.  Selection and recruitment of the sample of 93 chronic heart failure (CHF) patients.
CHF, six (2%) were younger than 45 years of age, and four
(1%) were residing in high level supported accommoda-
tion. A further 30 (11%) met the study eligibility but
declined to participate. Primary reason for declining was
that patients felt too unwell to take part in the study. There
were 101 patients that met the inclusion criteria and agreed
to participate in the study. However, post enrolment, eight
later requested to be withdrawn. Patients enrolled in the
study were significantly younger than those excluded
(73±11 vs. 76±13 years, Z=−3.5, p<0.001) but no signifi-
cant gender differences were observed.
Data was collected on 93 hospitalized CHF patients.
The primary investigator obtained informed consent from
each participant and conducted the patient interviews.
Participants were interviewed when they were regarded by
case managers to be clinically stable and every effort was
taken to conduct interviews with participants 24 hours prior
to discharge. Interviews were conducted a median of 5 days
(IQR 3 to 5 days) from hospital admission date. On five
occasions, interviews were conducted in participant’s
homes within 3 days of hospital discharge. Instruments
used to measure cognitive function, the MMSE,19 and the
MoCA,17 were administered at the time of the interview.
Descriptive data and physical and social factors collected
from the participant were: age, gender, social situation,
Charlson comorbidity index,25 NYHA functional class,26
depressive symptoms,27 experience with CHF diagnosis
(>2 months),28 level of education, medication, blood pres-
sure, and blood pathology.
Tools
To minimize the effect of test administration the MMSE
and MoCA were randomly delivered to ensure that one test
was not always delivered second.
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206 ineligible
(CHF diagnosis not confirmed)
169 excluded:
• 52 - NESB
• 56 - History of neurocog.
problems
• 14 - Poor visual / hearing
acuity
• 7 - Terminal Phase
• 6 - Under 45 years of age
• 4 - Residing in nursing
home
Mini Mental State Examination.  The MMSE19 is one of the
most widely used screening measures for dementia assess-
ing global neuropsychological functions.29 The MMSE
consists of 11 task items that assess the cognitive domains
of visuospatial skills, language, concentration, working
memory, memory recall, and orientation with a maximum
score of 30 (Table 1). Guidelines for the clinical adminis-
tration of MMSE recommend using scores 21–26 to clas-
sify MCI and scores <20 to classify moderate cognitive
impairment. The MMSE has satisfactory reliability, inter-
nal consistency and test–retest reliability, as well as high
levels of sensitivity for moderate-to-severe cognitive
impairment.30 Cut-off scores are usually reported at 24;
however, there is also evidence that using higher cut-off
scores of 27 (indicating less severe cognitive impairment)
is of prognostic importance.6,31 In a study comparing the
long-term outcomes from a CHF management programme6
patients with scores <27 on MMSE were more likely to be
readmitted and less likely to survive the 5-year follow up,
compared to patients with normal cognitive function and
randomized to usual care. This evidence supported the
decision to use a cut-off score of 27 in this study. A signifi-
cant advantage of the MMSE is that it can readily be used
in the clinical setting by nurses or allied health profession-
als, taking only 5–10 minutes to complete.32
Montreal Cognitive Assessment.  The MoCA17 was devel-
oped to specifically screen for MCI, a clinical condition
identified recently as impairment in one or more cognitive
domains that does not meet the criteria for dementia.13 The
MoCA assesses the cognitive domains of: visuospatial
skills, executive functions, language, attention, concentra-
tion, working memory, memory recall, and orientation.17 In
the instrument development study,17 the MoCA had higher
sensitivity compared with MMSE at detecting MCI (90%
4 European Journal of Cardiovascular Nursing 0(0)

Table 1.  Cognitive domains covered by Mini Mental State Exam (MMSE) and Montreal Cognitive Assessment (MoCA)

MMSE MoCA

Cognitive functions Task Points Cognitive functions Task Points

Visuospatial Copy intersecting pentagons 1 Visuospatial Clock drawing 3
  3-dimensional cube copy 1
  Executive Functions Alteration task (adapted 1
from Trail Making B Task)
  Phonemic fluency task 1  
  Two-item verbal abstraction 2  
task
Language Repetition (1 syntactically 1 Language Repetition (2 syntactically 2
complex sentence) complex sentences)
  Comprehend instructions 2  
  Read sentence and do as it 1 Confrontation naming task 3
says
  Write a short sentence 1  
  Recognize and name 3  
2 common objects
  Attention Sustained attention task 1
using tapping
Concentration Serial subtraction task or 5 Concentration Serial subtraction task 3
spell ‘WORLD’ backwards
Working memory Registration − repeat 3 Working memory Digits forward and 2
3 words backward
Memory recall Short-term memory recall 3 Memory recall Short-term memory recall 5
task task
Orientation Orientation to time and 10 Orientation Orientation to time and 6
place place

vs. 18%, respectively). Subsequently, this tool has been
shown to be a sensitive screening measure for MCI in
patients with cardiovascular disease,33,34 in patients with
CHF35 and cohorts with neurocognitive problems.36–38
Total possible score is 30 and the cut-score for MCI is 26.17
Low educational attainment is corrected by adding 1 point
to the participant’s final score for ≤12 years of formal
education.
In comparison to MMSE, the MoCA uses more words in
assessing memory, has fewer learning trials and a longer
delay before testing memory recall. Additionally, the
MoCA uses three tasks to assess different aspects of execu-
tive functions: an alternation task adapted from the trail-
making B task, a phonemic fluency task, and a verbal
abstraction task. Executive functions are not assessed by
the MMSE.
Ethical considerations
The study was approved by the relevant Human Research
Ethics Committees and conforms to the principles outlined
in the Declaration of Helsinki. It was determined that
patients with MCI had the capacity to understand a low-risk
study protocol and provide informed consent.39 In the event
that a patient scored <18 on the MMSE, suggesting
moderate cognitive impairment and possible dementia,
they were thanked for their participation but informed that
they did not meet the study eligibility. The participants’
medical team were also informed of the findings from the
screening.
Data management and statistical analyses
Continuous data for patient demographics is presented as
mean±standard deviation and categorical data is presented
as frequencies with 95% confidence intervals (CI) where
appropriate. Patients with scores <26 on MoCA or <27 on
MMSE were identified as cognitive scores suggestive of
MCI. Patients were coded as no MCI if their scores were
above the threshold on both the MoCA and MMSE. The
Kappa coefficient was used to examine the level of agree-
ment between scores suggestive of MCI classification
using the MoCA and MMSE.
The distribution of MMSE and MoCA scores (continu-
ous data) were skewed, as such comparisons between par-
ticipants with normal and abnormal scores on MoCA and
MMSE were conducted using Mann–Whitney U-test for
continuous data and Chi-squared test for categorical varia-
bles. Task errors were identified by patients providing one
or more incorrect responses for each assessed cognitive

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Cameron et al. 5
Table 2.  Mini Mental State Exam (MMSE) and Montreal
Cognitive Assessment (MoCA) scores for each cognitive domain
assessed
Cognitive domain assessed MMSE
Visuospatial   1 (1 to 1)
Language   7 (7 to 8)
Concentration/attention   5 (5 to 5)
Working memory   3 (3 to 3)
Memory recall   2 (1 to 3)
Orientation 10 (9 to 10)
Executive functioning − 3 (2 to 4)
Values are median (interquartile range).
domain. Chi-squared goodness-of-fit examined whether
patients with scores suggestive of MCI were more likely to
have task errors on each assessed cognitive domain, than
the hypothesized 30%. Statistical tests were two-sided and
a p-value ≤0.05 were considered statistically significant.
Data were analysed using SPSS (version 12.0.1 for
Windows, Chicago, IL, USA) and Creative Research
System calculator was used to calculate sample size.
G*power post-hoc test (McNemar) was used to determine
the power for the difference in the frequency of patients
with abnormal scores observed between the two screening
methods.
Results
Descriptive data
Overall, the study sample had a mean age 70±11 years, was
predominantly male (71%), and less than one-third had a
diagnosis of CHF <2 months. Thirty-nine were living alone,
and most (77%) had not completed more than 12 years of
formal education. Forty-four (47%) were functionally com-
promised (NYHA III or IV), 40 (43%) had a medium
Charlson comorbidity index score and only 25 (27%) had no
evidence of depressive symptoms. The majority of patients
had been prescribed pharmacotherapy considered gold
standard in the treatment of CHF.24 Seventy-eight (84%) had
been prescribed an angiotensin converting enzyme inhibitor
or an angiotensin-II receptor antagonist and seventy-nine
(85%) had been prescribed a beta-blocker. The median scores
on the MoCA was 24 (IQR 21.5 to 26) as compared with 28
(IQR 26 to 28.5) on the MMSE. The median scores for each
cognitive domain assessed are listed in Table 2.
MoCA vs. MMSE
Twenty-five participants had scores ≥26 on the MoCA and
≥27 on the MMSE (No MCI) and 68 were observed to have
low scores suggestive of MCI and the need for further cog-
nitive testing (Table 3). Participants with scores ≥26 on the
MoCA and ≥27 on the MMSE were significantly 8 years
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younger (U=495, Z=–3.08, p<0.01, r=0.3) than those with
low scores suggestive of MCI. No statistically significant
differences were evident for demographic (gender, living
MoCA alone, educational level) or clinical variables between par-
ticipants with low scores and those with scores ≥26 on the
3 (3 to 4) MoCA and ≥27 on the MMSE.
4 (3.5 to 5) There were statistically more participants with MoCA
4 (5 to 6) scores <26 as compared with MMSE scores <27 (71% vs.
2 (2 to 2) 32%, χ2[1]=9.2, p=0.02) (Table 4). Of the 66 participants
2 (1 to 3)
with MoCA scores <26, 38 (41%) had MMSE scores ≥27.
6 (5 to 6)
Conversely, of the 30 participants with MMSE scores <27,
two (2%) participants had MoCA scores ≥26. The Kappa
measure of agreement was 0.25 (p=0.001) indicating a sig-
nificantly low level of agreement between classifying cases
as MCI using MoCA compared with MMSE. McNemar
post-hoc power test demonstrated that the sample size of 93
had sufficient power (<0.9) to detect a significant differ-
ence between the two assessments.
A number of differences emerged when MoCA task
errors were compared with MMSE task errors in the 68 par-
ticipants with low cognitive scores (MMSE scores <27 or
MoCA scores <26) (Figure 2). When examining task errors,
substantially more participants were observed to have
errors on the MoCA cognitive domains compared with the
MMSE cognitive domains. The MoCA uses two tasks to
assess visuospatial function; 46 (68%) participants had task
errors on this cognitive domain. In contrast, the MMSE
uses only one task to assess visuospatial functioning (copy
intersecting pentagons); 15 (22%) participants had errors in
completing this task. Sixty-six (96%) participants with
MoCA scores <26 had errors on delayed memory recall
compared with 75% on the equivalent memory recall task
of the MMSE. Fifty-five (81%) participants with scores
<26 on the MoCA, had task errors on three executive func-
tion items – a domain not assessed by the MMSE.
The Chi-squared goodness-of-fit test indicated that there
was a significant difference in the proportion of patients with
scores suggestive of MCI (<26 on the MoCA and <27 on the
MMSE) having task errors on each of the six cognitive
domains assessed by the MoCA compared with only three of
the five cognitive domains assessed by the MMSE (Table 5).
Discussion
In a select sample of CHF patients chosen because they had
no documented history of neurocognitive problems, evi-
dence of low cognitive scores suggestive of MCI was evi-
dent in 73% of this sample. This was double the rate
anticipated and observed in other studies22,23 and supports
our first hypothesis that at least 30% of the sample would
be identified as having cognitive scores suggestive of MCI.
Furthermore, it raises the issue that as these cognitive
impairments were not otherwise indicated in the patients’
medical history, supplementary neurocognitive investiga-
tion may have been warranted.
6 European Journal of Cardiovascular Nursing 0(0)

Table 3.  Socio-demographics and clinical characteristics in a sample of 93 chronic heart failure patients

Overall (n=93) No MCI (MoCA ≥26 and Low cognitive scores (MoCA
MMSE ≥27) (n=25) <26 or MMSE <27) (n=68)
Female 27 (29) 6 (6.5) 21 (22.6)
Lived alone 39 (42) 9 (10) 30 (32)
Less than 12 years education 72 (77) 20 (22) 52 (55)
NYHA class III to IV 44 (47) 14 (15) 30 (32)
Diagnosis <2 months 28 (30) 4 (4) 24 (26)
Renal impairment (serum creatinine >120 µmol/l) 50 (54) 15 (16) 35 (38)
Charlson comorbidity index 3−4 40 (43) 9 (10) 31 (33)
Anaemic (serum Hb <100 g/l) 18 (19) 6 (6) 12 (13)
Prescribed ACE-I or ARB 78 (84) 24 (26) 54 (58)
Prescribed beta-blocker 79 (85) 21 (23) 58 (62)

Values are n (%). ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin-II receptor antagonists; MCI, mild cognitive impairment; MMSE,
Mini Mental State Exam; MoCA, Montreal Cognitive Assessment; NYHA, New York Heart Association classification.

Table 4.  Evidence of cognitive scores suggestive of mild 70 MMSE 96%

cognitive impairment in a sample of chronic heart failure MoCA
60 81%
patients (n=93) 81%
75%
50 68% 68%
Screening measure Threshold score Sample
40
MoCA <26 66 (71) n 47% 49%
MMSE <27 30 (32) 43%
30
Low cognitive function <26 on MoCA or <27 on 68 (73)
20 25%
MMSE 22%
Intact cognitive function ≥26 on MoCA and ≥27 on 25 (27) 10
MMSE
0
Values are n (%). MMSE, Mini Mental State Exam; MoCA, Montreal
Cognitive Assessment.

The MoCA identified in excess of a third more CHF

patients with cognitive scores suggestive of MCI than the
MMSE. As such, this evidence supports the second hypothe-
sis that the MMSE and MoCA differ in the level of agreement
in identifying cognitive impairments suggestive of MCI.
Other investigators40 have recently examined the differ-
ences between the MMSE and MoCA in screening for MCI
in CHF patients. However, the investigators33 used a cut-off
score ≤24 for the MMSE to define cognitive impairment
and testing had not been conducted in the acute care hospi-
tal setting. Although there were differences in the propor-
tions of participants having low cognitive scores on the
MMSE compared with the MoCA, this difference was not
statistically significant,40 but has implications of clinical
significance.
Examination of the cognitive domains assessed by the
MMSE and compared with the MoCA has been scrutinized
by other investigators.40–42 Our study adds to this body of
knowledge that discrete differences between the MMSE
and MoCA are evident. Specifically, an examination of the
task errors in the 68 participants with scores indicative of
MCI revealed these participants had more task errors on
cognitive domains assessed by the MoCA compared with
the MMSE. On the MoCA, more than 80% of participants
Cognive domains
Figure 2.  Differences in the frequency of observed task
errors between Mini Mental State Exam (MMSE) and Montreal
Cognitive Assessment (MoCA) in patients with low cognitive
scores suggestive of mild cognitive impairment (n=68).
with scores suggestive of MCI had task errors on language,
memory recall, and executive functions. Conversely, fewer
task errors were observed on the cognitive domains of the
MMSE. This discrepancy not only in the suggestive preva-
lence of MCI, but also in discrete differences in task errors
between the two screening methods may reflect the underly-
ing function of each screening tool: MCI versus dementia.
The MMSE is widely used as a frontline screening for
dementia and to assess cognitive changes over time, how-
ever its accuracy in detecting MCI is limited.29,30 Suggested
reasons for this are the propensity of relatively easy verbal
item tasks that do not have the sensitivity to identify subtle
language deficits and insufficient items to adequately meas-
ure visuospatial and constructional praxis.30 In contrast,
the MoCA was specifically developed to screen for MCI
where individuals have reported a cognitive decline over a

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Cameron et al. 7

Table 5.  Differences in proportions of task errors on the scores. As such, this may have resulted in an over estima-
cognitive domains: MMSE vs. MoCA (n=68) tion of cognitive scores suggestive of MCI.44 To address
Cognitive domain assessed Chi-squared goodness p-value
this limitation, every effort was taken to conduct the screen-
of fit (df=1) ings as close to discharge, when patients were relatively
stable. Nonetheless, there was a strong rationale for choos-
MMSE ing this particular time point; this is when many patients are
 Visuospatial 2.04 0.15 provided with complex information about self-managing
 Language 45.89 <0.001 their condition. Our findings lend weight to the argument
 Concentration 0.81 0.37
that hospitalization is not the most appropriate time to
  Memory recall 65.57 <0.001
deliver complex patient education45 as many patients with
 Orientation 11.11 0.001
CHF may not have the cognitive capacity to remember,
MoCA
retain, and process such information. Further research is
 Visuospatial 45.9 <0.001
  Executive functions 88.75 <0.001
required to investigate the trajectory of MCI and deter-
 Language 83.84 <0.001 mine the optimal time point not only in screening for this
 Attention/concentration/ 9.42 <0.002 comorbidity but to also in providing comprehensive patient
working memory education.
  Memory recall 139.3 <0.001 Age, education, and cultural background may also
 Orientation 5.18 0.02 impact on MMSE scores.20,30 These limitations may account
for the differences in low cognitive scores suggestive of
In this sample 73% of patients had cognitive scores suggestive of MCI MCI when either the MMSE or MoCA had been adminis-
compared with 30% obtained in other samples. MMSE, Mini Mental State
Exam; MoCA, Montreal Cognitive Assessment. tered. The Kappa statistic makes no distinction among
sources of disagreement potentially resulting in an underes-
timation of agreement.46 As such, this study provides strong
12-month period.17,43 Previous research has identified that
evidence that the MoCA and MMSE differ widely in clas-
this group of dementia-free individuals would score in the
sifying MCI in CHF patients. The MCI classification was
normal range of the MMSE.17 Similarly, many CHF patients
not validated as a neuropsychological battery was not
living in the community are more likely to fulfil the clinical
administered nor was a comparison group included in the
criteria for MCI as opposed to dementia.11
study design. As such, the MoCA may have over identified
Our study demonstrates that in comparison to the MMSE,
cognitive impairment and it was not possible to demon-
the MoCA is a more clinically effective screening measure
strate that either screening tool was psychometrically more
in the detection of inconspicuous cognitive impairments in
robust or had greater sensitivity or specificity than the
patients living with CHF. As such, there is now sufficient
other. The administration of neuropsychological battery
and compelling evidence to recommend using the MoCA
and a comparison group would have assisted in addressing
over the MMSE in screening for MCI in CHF patients.
this. Future research that address these limitations are war-
ranted to demonstrate the optimal screening method and to
Relevance to clinical practice make recommendations for clinical practice.
Unless purposefully screened, cognitive impairments in
patients with CHF are often unrecognized by health profes- Conclusion
sionals. Considering the high prevalence rates of cognitive
impairments, screening for MCI in CHF patients should In this sample of CHF patients, cognitive impairments that
become routine practice. In this manner, resources in the would otherwise have been unrecognized were found in
form of support and surveillance can be appropriately 73% of the sample. Cognitive domains most frequently
directed to the more vulnerable patients.6,8 Of the screening identified as impaired were those required for learning and
measures that are available to nurses, the MoCA provides developing self-care management skills. Of the two screen-
valuable information about cognitive domains that are ing measures administered, the MoCA identified an addi-
often diminished in CHF patients. Referral for comprehen- tional 38 patients with low cognitive scores suggestive of
sive and in-depth neuropsychological assessment may need MCI that otherwise would not have been identified by the
to be considered if cognitive impairments persist over time, MMSE. These findings indicate that, in screening for MCI,
despite optimal treatment. the MoCA over the MMSE will identify CHF patients most
vulnerable to poor health outcomes.

Limitations Funding
The standalone screening was undertaken during the hospi- JC was funded by an NHMRC/NHF public health postgraduate
tal admission phase when potentially confounding factors scholarship (ID 323403) to undertake this research as part of
have the potential to influence neuropsychological test her PhD.

Downloaded from cnu.sagepub.com at Monash University on April 23, 2012

8 European Journal of Cardiovascular Nursing 0(0)
Acknowledgements
Gratitude is extended to the CHF nurses at St Vincent’s public
hospital and Eastern Health Network (Melbourne) who assisted in
17. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal
screening and referring patients to the study. Appreciation is also
extended to Ms Skye McLennan (psychologist) who provided
valuable feedback on the manuscript.
18. Ismail Z, Rajji TK and Shulman KI. Brief cognitive screen-
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