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TEST PERFORMANCE OF MONTREAL COGNITIVE ASSESSMENT

FOR ASIAN CULTURE: A LITERATURE REVIEW

A Requirement in PhD GC 611

Methods of Assessment I

Submitted to :

Dr. Gina R. Lamzon, RGC, RPm

Professor

Submitted by:

DESIREE O. LABIO, RGC

PhD GC - 1
 TEST PERFORMANCE OF MONTREAL COGNITIVE ASSESSMENT FOR ASIAN CULTURE: 2021
A LITERATURE REVIEW

OCTOBER 2021
Introduction

The aim of this paper is to review literatures on the test performance of the
adapted versions of Montreal Cognitive Assessment (MoCA) used for Asian culture.

The Montreal Cognitive Assessment (MoCA) is a cognitive screening instrument

developed to detect mild cognitive impairment (MCI).It is a simple 10 minute paper and
pencil test that assesses multiple cognitive domains including memory, language,
executive functions, visuo-spatial skills, calculation, abstraction, attention,
concentration, and orientation.

Thirty items assessing multiple cognitive domains are contained in the

MoCA: short-term memory (5 points); visuospatial abilities via clock drawing (3 points),
and a cube copy task (1point); executive functioning via an adaptation of Trail Making
Test Part B (1 point), phonemic fluency (1 point), and verbal abstraction (2 points);
attention, concentration, and working memory via target detection (1 point), serial
subtraction (3 points), digits forward (1 point), and digits backward (1 point); language
via confrontation naming with low-familiarity animals (3 points), and repetition of
complex sentences (2 points); and orientation to time and place (6 points) (Nasreddine
et al., 2005).

The MoCA is scored by obtaining an item total and the authors recommend a
clinical cut-off score of 26. . It has been translated into 36 languages and additional
alternative forms, yet only a small number have been validated and nearly all versions
lack population based data of individuals aged 80 and older ( Tan et al, 2015).

Test performance is known to be influenced by age, education, and language.

Values and beliefs can also affect neuropsychological testing.7 The issue of how culture
and language affect test performance has been a topic of concern in past decades.8,9
Floor effects have been apparent when English tests were administered to non-native
populations in the US, particularly because of the high cultural bias of some of the items
found in the tests.10 Thus, particularly for screening instruments used in the medical
field, cross-cultural adaptation is imperative. Important aspects in cross-cultural
adaptation are reliability, content, and construct validity. Careful forward translation,
synthesis, back-translation, expert judging, and pre-final testing components are
needed.11,12 Most importantly, contextual adaptation by using experiential and
conceptual equivalence to the culture where the instrument is being adapted to must be
meticulously accorded.13 In an Asian countries.
 TEST PERFORMANCE OF MONTREAL COGNITIVE ASSESSMENT FOR ASIAN CULTURE: 2021
A LITERATURE REVIEW

TEST PERFORMANCE

The study of Tian et al (2020) on the validation of the Beijing version of the
Montreal Cognitive Assessment in Chinese patients undergoing hemodialysis reveals
that the MoCA-BJ offers good sensitivity and specificity levels in detecting cognitive
impairment in hemodialysis patients. Cognitive impairment was diagnosed in 75.69% of
the patients using the , MoCA-BJ. Spearman's rank correlation analysis indicated that
the MoCA-BJ was significan

tly correlated with the neuropsychological battery (rs = 0.639, p<0.001). The area
under the ROC curve for cognitive impairment diagnosis using the MoCA-BJ was 0.891
(95% confidence interval: 0.859-0.924). The optimal MoCA-BJ cutoff score in
discriminating patients with and without cognitive impairment was 24 points with a
sensitivity of 0.877 and specificity of 0.752. These findings support the utility of the
MoCA-BJ as a screening tool for cognitive impairment in Chinese patients undergoing
hemodialysis (Tian et al, 2020).

However, the Chinese short versions (sensitivity 0.89/0.90, specificity 0.72/0.77) are
similar in performance to the full MoCA in identifying cognitive impairment (sensitivity
0.91, specificity 0.82). The results indicated that s-MoCAs had high diagnostic accuracy
across neurological disorders, including different types of dementia and MCI. The
overall high sensitivity and specificity may be because the items selected for the s-
MoCA span several neurocognitive domains. These short variants of the MoCA may
serve as quick and effective instruments when the original MoCA cannot be feasibly
administered in clinical services with a high patient burden and limited cognitive testing
resources (Tan et al , 2021)

A study of investigation on the validity and reliability of the alternate versions of the
Montreal Cognitive Assessment (Hong Kong version) in patients with DSM-5 Mild
Neurocognitive Disorder (Mild NCD) and cognitively healthy controls revealed that in
terms of concurrent validity, HK-MoCA-O and versions significantly correlated with the
HK-MoCA-O, with higher correlation observed for the HK-MoCA-A1 (r = 0.87, p<0.001)
than the HK-MoCA-A2 (r = 0.79, p<0.001). The Bland Altman plot revealed a small
mean difference in total score between the original and the alternate version (0.17 and -
0.40 point for HK-MoCA-A1 and HK-MoCA-A2, respectively). It also showed a
 TEST PERFORMANCE OF MONTREAL COGNITIVE ASSESSMENT FOR ASIAN CULTURE: 2021
A LITERATURE REVIEW

consistent level of agreement throughout the whole range of performance on the HK-
MoCA-O, meaning that the difference (bias) between original and each alternate version
was similar throughout the entire range of cognitive ability. Note that the mean score
difference of the two alternate versions with HK-MoCA-O was 0.17 point for HK-MoCA-
A1 and -0.40 point for HK-MoCA-A2. Such differences may be considered minimal for
both clinical and research use (Wong A, et al (2018).

This is also the first study to examine the validity of the MoCA in screening of Mild NCD.
We showed that the original and alternate versions are all sensitive to Mild NCD. It is
notable that the AUC observed for the HK-MoCA-A1 (0.922) was slightly higher than
that of HK-MoCA-O (0.839), indicating that the HK-MoCA-A1 has better discriminating
ability than HK-MoCA-A2. Given that the classification of Mild NCD was made partially
on the basis of performance on the HK-MoCA-O, the difference in criterion validity
between the two alternate versions is possibly explained by the higher correlation with
the HK-MoCA-O observed for the HK-MoCA-A1 than the HK-MoCA-A2. Therefore,
despite that both alternative versions are valid and reliable, preference is given to HK-
MoCA-A1 in view of the better psychometric properties of this version over HK-MoCA-
A2.

CONCLUSION

In conclusion, the findings of this review imply that using cut-offs and point adjustments
for education, as suggested by validation authors, would be more acceptable. The ‘low'
quality of validation papers and the possibility of overestimation of accuracy highlighted
the necessity for clinicians and researchers to use the MoCA correctly, that is, as a
quick, cognitive screening tool to identify individuals who may require a more extensive
examination. Furthermore, it is critical to emphasize that test results should be
evaluated in conjunction with other clinical data, such as clinical history, collateral
information, and behavioral observations (Wong, 2015). It should be emphasized that,
while the MoCA has been adapted across languages and cultures, it does not take
acculturation variables into consideration. Using cognitive screens to acquire objective
data can be applied; nevertheless, this review highlights the limitations and applicability
of using versions of the MOCA in the context of individual and cultural influences.
 TEST PERFORMANCE OF MONTREAL COGNITIVE ASSESSMENT FOR ASIAN CULTURE: 2021
A LITERATURE REVIEW

Furthermore, the reported range of cut-offs in validated papers suggests that employing
unvalidated metrics and straight translations has dubious utility.

Thus, the MoCA promises to be a potentially useful, sensitive and specific cognitive
screening instrument for detection of Mild Cognitive Impairment in multiple neurological
and systemic disease that affect cognition across various cultures and languages.

Few cognitive assessment tools have been validated in Asia, with no published
validation studies for many Asian nations and languages. In addition, many available
tools display educational bias. Future research should include concerted efforts to
develop culturally appropriate tools with minimal educational bias.

Contextual translation and pilot testing yielded several modifications in the adaptation of
the MoCA for use in the Philippines. Pre-testing study showed that the MoCA-P is a
reliable instrument for use in the Filipino elderly. Due to the variability of responses that
can be considered as correct by testers and subjectivity in rating responses, a manual
of instructions must be developed to standardise test administration, rating, and
interpretation. Further diagnostic validation of the MoCA-P to establish cutoff scores that
would discriminate elderly individuals with normal cognition from those with dementia is
needed to establish the clinical utility of the test.

References:

Julayanont, P., Phillips, N., Chertkow, H., and Nasreddine, Z.S. The Montreal Cognitive
Assessment (MoCA): Concept and Clinical Review. To appear in A.J. Larner
(Ed.), Cognitive Screening Instruments: A Practical Approach. Springer-Verlag,
pp. 111-152.

Dominguez JC, Giron MS. Long Term Treatment of AD With Donepezil In A Clinical
Practice
Setting In An Asian Population. Alzheimers Dement 2006;2(Suppl 1):P3-464.
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Geldmacher DS, Provenzano G, Mcrae T, Mastey V, Ieni JR. Donepezil Is Associated

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A LITERATURE REVIEW

Tan, J. P., Wang, X., Zhang, S., Zhao, Y., Lan, X., Li, N., ... & Gao, J. (2021). Accuracy
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