Normative data for the Montreal Cognitive Assessment (MoCA) in a population-based sample.
ABSTRACT To provide normative and descriptive data for the Montreal Cognitive Assessment (MoCA) in a large, ethnically diverse sample.
The MoCA was administered to 2,653 ethnically diverse subjects as part of a population-based study of cardiovascular disease (mean age 50.30 years, range 18-85; Caucasian 34%, African American 52%, Hispanic 11%, other 2%). Normative data were generated by age and education. Pearson correlations and analysis of variance were used to examine relationship to demographic variables. Frequency of missed items was also reviewed.
Total scores were lower than previously published normative data (mean 23.4, SD 4.0), with 66% falling below the suggested cutoff (<26) for impairment. Most frequently missed items included the cube drawing (59%), delayed free recall (56%; <4/5 words), sentence repetition (55%), placement of clock hands (43%), abstraction items (40%), and verbal fluency (38%; <11 words in 1 minute). Normative data stratified by age and education were derived.
These findings highlight the need for population-based norms for the MoCA and use of caution when applying established cut scores, particularly given the high failure rate on certain items. Demographic factors must be considered when interpreting this measure.
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ABSTRACT: Introduction: Cognitive deficits are an important determinant for experiencing limitations in occupational performance after stroke. It is important to recognize these deficits, and their impact on daily activities, at an early stage so people can get the support they need. The non-challenging environment of a hospital hampers this recognition, making it difficult for occupational therapists to select which patients should be assessed extensively, and which not. This study aims to explore the Montreal Cognitive Assessment as a screening tool by investigating its relationship with occupational performance in patients with mild stroke.Method: Twenty-nine people with mild stroke were recruited for this cross-sectional study. Scores on the Montreal Cognitive Assessment and Assessment of Motor and Process Skills were compared and correlations were calculated.Findings: The Montreal Cognitive Assessment cut-off did not identify those who might experience problems in daily functioning after mild stroke. A moderate correlation was found between scores on the Montreal Cognitive Assessment and the Assessment of Motor and Process Skills process scores.Conclusion: The Montreal Cognitive Assessment cannot be used as a screening tool to identify problems in occupational performance after mild stroke.The British Journal of Occupational Therapy. 10/2014; 77(10).
Dataset: MOCA normative
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ABSTRACT: The Montreal Cognitive Assessment (MoCA) is a rapid screening battery, also including subtests to assess frontal functions such as set-shifting, abstraction and cognitive flexibility. MoCA seems to be useful to identify non-amnestic mild cognitive impairment (MCI) and subcortical dementia; it has high sensitivity and specificity in distinguishing MCI from mild Alzheimer's Disease. Previous studies revealed that certain items of MoCA may be culturally biased and highlighted the need for population-based norms for the MoCA. The aim of present study was to collect normative values in a sample of Italian healthy subjects. Four hundred and fifteen Italian healthy subjects (252 women and 163 men) of different ages (age range 21-95 years) and educational level (from primary to university) underwent MoCA and Mini Mental State Examination (MMSE). Multiple linear regression analysis revealed that age and education significantly influenced performance on MoCA. No significant effect of gender was found. From the derived linear equation, a correction grid for MoCA raw scores was built. Inferential cut-off score, estimated using a non-parametric technique, is 15.5 and equivalent scores were computed. Correlation analysis showed a significant but weak correlation between MoCA adjusted scores with MMSE adjusted scores (r = 0.43, p < 0.001). The present study provided normative data for the MoCA in an Italian population useful for both clinical and research purposes.Neurological Sciences 11/2014; · 1.50 Impact Factor
2011;77;1272-1275 Published Online before print September 14, 2011
Heidi C. Rossetti, Laura H. Lacritz, C. Munro Cullum, et al.
in a population-based sample
Normative data for the Montreal Cognitive Assessment (MoCA)
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Normative data for the Montreal
Cognitive Assessment (MoCA) in a
Heidi C. Rossetti, PhD
Laura H. Lacritz, PhD
C. Munro Cullum, PhD
Myron F. Weiner, MD
Objective: To provide normative and descriptive data for the Montreal Cognitive Assessment
(MoCA) in a large, ethnically diverse sample.
Methods: The MoCA was administered to 2,653 ethnically diverse subjects as part of a
population-based study of cardiovascular disease (mean age 50.30 years, range 18–85; Cauca-
sian 34%, African American 52%, Hispanic 11%, other 2%). Normative data were generated by
age and education. Pearson correlations and analysis of variance were used to examine relation-
ship to demographic variables. Frequency of missed items was also reviewed.
Results: Total scores were lower than previously published normative data (mean 23.4, SD 4.0),
with 66% falling below the suggested cutoff (?26) for impairment. Most frequently missed items
included the cube drawing (59%), delayed free recall (56%; ?4/5 words), sentence repetition
(55%), placement of clock hands (43%), abstraction items (40%), and verbal fluency (38%; ?11
words in 1 minute). Normative data stratified by age and education were derived.
Conclusion: These findings highlight the need for population-based norms for the MoCA and use
of caution when applying established cut scores, particularly given the high failure rate on certain
items. Demographic factors must be considered when interpreting this measure. Neurology®
The Montreal Cognitive Assessment (MoCA) is a brief measure of global cognitive function
originally developed to detect mild cognitive impairment (MCI), often a precursor to Alzhei-
mer disease (AD). This instrument is now used throughout the world as a measure of general
cognitive function (www.mocatest.org). The suggested normal range for the MoCA (26–30
points) was developed based on a sample of 90 healthy Canadian controls (mean age 72.84
[7.03] years; mean education 13.33 [3.40]), using a one-point education correction (?12
years).1MoCA normative data are thus limited, as little is known about its normative properties
within the general population and across a wider age and education range. MoCA translations have
been examined in multiple international populations2-6; however, there are no normative data for
the general US population. The present study aims to provide normative MoCA data stratified by
age and education in a large, ethnically diverse, population-based sample.
METHODS Participants. This investigation was conducted as part of the Dallas Heart Study (DHS), a longitudinal, population-
based, multiethnic study of factors contributing to progression from normal health to being at risk for cardiovascular disease. In this
study, African Americans were oversampled to ensure approximately 50% African American representation.7The first phase of DHS
(DHS-I) was initiated in 2001. DHS-I participants and spouses were recruited to DHS-II, which gathered data from September 2007
to January 2010. The MoCA was administered to 2,880 subjects from DHS-II.
All participants met the following inclusion criteria: 1) able to speak and comprehend English, 2) able to provide informed
consent, and 3) completed a valid MoCA test. One participant was excluded because he requested that his data not be used. Forty-five
From the Departments of Psychiatry (H.C.R., L.H.L., C.M.C., M.F.W.) and Neurology and Neurotherapeutics (L.H.L., C.M.C., M.F.W.),
University of Texas Southwestern Medical Center at Dallas, Dallas. H. Rossetti is now affiliated with the Department of Psychiatry and
Neurobehavioral Sciences, University of Virginia, Charlottesville.
Study funding: Supported in part by the Donald W. Reynolds Foundation and the Wallace, Barbara, and Kelly King Foundation.
Disclosure: Author disclosures are provided at the end of the article.
Address correspondence and
reprint requests to Dr. Heidi C.
Rossetti, P.O. Box 800203,
Charlottesville, VA 22908
Copyright © 2011 by AAN Enterprises, Inc.
duplicate entries were removed and another 29 were deleted due
to missing data that prevented the calculation of a MoCA total
score. Thirty-six individuals were excluded due to positive stroke
history and one was removed due to unclear stroke history. The
MoCA was given in Spanish to 114 primarily Spanish-speaking
participants using the Spanish MoCA protocol but were ex-
cluded for the purposes of this study in order to focus on the
English version of the test. Following these exclusions, there
were 2,653 participants available for the current study.
Measures. The MoCA is a 30-point screening tool that re-
quires approximately 10 minutes to administer and evaluates as-
pects of attention, orientation, language, verbal memory,
visuospatial, and executive function. The MoCA items have
been described in detail elsewhere.1
Procedures. MoCA testing was conducted during the partici-
pants’ day-long DHS-II visit, and attempts were made to admin-
ister the test at the beginning of the protocol to minimize the
effects of fatigue. The MoCA was administered by trained per-
sonnel, scored in the conventional manner, and double-checked
for accuracy. The suggested 1-point correction for ?12 years of
education was not applied, as one of the aims of the study was to
generate normative data across education levels. After scoring,
the deindentified MoCA data were entered item-by-item in the
DHS-II database using only the study identifier. In an effort to
screen for possible cognitive impairment, participants were asked
3 additional yes/no questions prior to completing the MoCA:
whether they believed they had any problems with their mem-
ory, if those problems interfered in daily functioning, and if they
had any difficulty solving problems.
Standard protocol approvals, registrations, and patient
consents. All participants provided written informed consent
to participate and the study protocol was approved by the Insti-
tutional Review Board of UT Southwestern Medical Center.
Statistical analysis. Statistical analyses were conducted using
SPSS version 18.0 (SPSS, Inc., Chicago IL). The frequency of
missed items was reviewed, and Pearson correlations were em-
ployed to demonstrate relationships between demographic vari-
ables (age and education) and MoCA performance. Additionally,
MoCA scores for those who endorsed one or more self-
reported cognitive complaints were compared to those with
no cognitive complaints using analysis of covariance, covary-
ing for age and education.
After the establishment of demographic-dependent differ-
ences, overlapping age ranges were utilized based on previously
described rationale.8This method provides larger sample sizes in
each group for more reliable data and allows clinicians to choose
the age group that corresponds best with the age of a patient
(e.g., a 55-year-old patient may be better represented in the age
range in which he or she falls toward the midpoint [50–60] than
at the extreme [45–55]). The age groups were subdivided into 3
groups each, according to their educational level: ?12 years of
education, 12 years of education, and ?12 years of education.
RESULTS Demographic characteristics of the sam-
ple are presented in table 1. Of the 2,653 partici-
pants, 60% were women. The mean age of the
sample was 50.30 years (SD 11.20) and the average
education level was 13.35 years (SD 2.50). MoCA
scores were weakly but significantly correlated with
age (r ? ?0.21, p ? 0.001), more strongly associ-
ated with education (r ? 0.42, p ? 0.001), and had
no relation to gender.
MoCA total scores (mean 23.36, SD 3.99), even
when using the suggested 1-point education correc-
tion (mean 23.78, SD 3.81), were lower than ex-
pected given previously published normative data,1
with the majority of scores falling below the sug-
gested cutoff (?26) for impairment (66% without
education correction; 62% with correction). Further,
mean scores for each of the 3 ethnicities and for every
age group at each of the 3 educational levels fell be-
low the cutoff. The most frequently missed items in-
cluded drawing a cube (59%), delayed free recall
(56%; ?4/5 words), sentence repetition (55%),
placement of clock hands (43%), abstraction (40%),
and verbal fluency (38%; ?11 words in 1 minute).
MoCA performance differed significantly based
on participants’ self-report of memory problems,
memory interference, and executive functioning
problems, as those who endorsed 1 or more of the 3
screening questions (n ? 505) scored significantly
tive complaints (mean 23.68, SD 3.84; F1,2508?
21.84, p ? 0.001). Participants with self-identified
cognitive complaints were subsequently excluded from
the presentation of normative data.
Normative data stratified by age and education
were derived. As can be seen in table 2, variance in
MoCA scores was greatest in those with ?12 years of
DISCUSSION This study provides age- and
education-stratified normative data for the MoCA
derived from a large, population-based sample. As
expected, participants with more years of education
obtained higher MoCA scores. Cognitive perfor-
mance as measured by the MoCA decreased only
slightly with age in those with ?12 years of educa-
tion, and more so in those with lower education.
Table 1Demographic characteristics
2,653 6050.30 (11.20)13.35 (2.50)23.36 (3.99)
1,419 (54)6449.87 (11.27)c
12.92 (1.96)22.01 (4.00)
875 (33) 5552.27 (10.81)b
292 (11)5946.67 (10.80)12.08 (3.21)e
57 (2) 3749.33 (11.69)14.72 (2.43)23.44 (3.84)
Abbreviation: MoCA ? Montreal Cognitive Assessment.
aMoCA scores without the 1-point education correction.
bWhites significantly older than black and Hispanic groups, p ? 0.001.
cBlacks significantly older than Hispanic group, p ? 0.001.
dWhites significantly more years of education than black and Hispanic groups, p ? 0.001.
eHispanics significantly less years of education than all other groups, p ? 0.001.
fWhites significantly higher MoCA scores than all other groups, p ? 0.001.
Neurology 77 September 27, 2011
Given that the MoCA is a multimodal screening
tool, individual items may not be equally affected by
age or other demographic factors.9As this was a
population-based sample, there was also the possibil-
ity of a survivor effect10wherein older persons might
have had more age-associated comorbid conditions
and been more likely to die, be in long-term care
facilities, or otherwise be unable to participate.
Even with the suggested 1-point education cor-
rection, the majority (62%) of participants in the
present sample scored below the published cutoff of
?26 points, indicating that this cutoff and the
1-point correction may not be appropriate or ade-
quate in similar groups. Furthermore, using the
1-point correction has actually been found to ad-
versely affect the reliability of the MoCA in some
samples.11We suggest utilizing the normative data
presented here in table 2, which are based on the
mean and SD in each age/educational achievement
Differences in MoCA scores by ethnic groups
were not compared since such variations cannot be
attributed to ethnicity per se; rather, they are likely
the result of other factors such as differences in qual-
ity of education and acculturation. Early education is
now thought to play a large, if not the largest, role in
many of the differences in cognition functioning that
were previously interpreted as race-related.12Further-
more, African American or Hispanic ethnicity in this
Dallas sample may be quite different from similarly
labeled groups in other locations. The purpose of this
article was not to attempt to dissect ethnicity effects,
but to underscore that the existing MoCA normative
data may not be applicable to diverse patient popula-
tions, and highlight the need for caution when inter-
preting MoCA scores in multicultural situations,
especially among those with lower levels of education.
Since this was a population-based study, partici-
pants were not formally screened for conditions
(other than stroke) that could potentially have an ef-
fect on cognition. As such, the sample may have in-
cluded individuals with undetected neurologic
comorbidities. However, those with self-reported
memory or cognitive problems were excluded in an
effort to reduce possible inclusion of those with pre-
clinical or very early dementia. Along these lines, it
should be noted that the relatively small sample size
(n ? 79) for the 70- to 80-year-old group is a limita-
tion, as the MoCA is often used in this age group. In
terms of other potential confounds, we have exam-
ined the effects of cerebrovascular risk factors (e.g.,
diabetes, hypertension, hypercholesterolemia) on
MoCA scores in separate investigations (currently in
submission) and found that these factors did not ac-
count for a significant degree of variance in MoCA
performance. Although the MoCA has been found to
be more sensitive than tests such as the Mini-Mental
State Examination in some studies,13-16it is a screen-
ing tool for global cognition and may not work as
well for estimating levels of impairment. Certain
items are scored using a yes/no (i.e., credit or no
credit) format (e.g., verbal fluency), which limits the
measure’s ability to provide qualitative assessment re-
garding extent of difficulties, and some items may
suffer from greater cultural bias than others. Finally,
without the benefit of clinical evaluations on the sur-
vey in this study, we were unable to correlate MoCA
scores with a clinical diagnosis.
These results highlight the need for the use of
population-based MoCA norms and suggest caution
Table 2 Montreal Cognitive Assessment score by age and education level
Age group, y
Years of education
Total by age
2022.80 (3.38) 2365 24.46 (3.49) 25 12225.93 (2.48) 26 20725.16 (3.08) 26
3722.84 (3.18) 23106 23.99 (2.93) 2426425.81 (2.64) 2640825.07 (2.95) 25
5522.11 (3.33) 23177 23.02 (3.67) 24 35525.38 (3.05) 26 58824.37 (3.51) 25
77 21.36 (3.73) 2222722.26 (3.94) 23 41825.09 (3.16) 26 72323.80 (3.80) 24
7720.75 (3.80) 21 21621.87 (3.95) 22 461 24.70 (3.24) 2575523.48 (3.84) 24
6219.94 (4.34) 20 17222.25 (3.46) 2242424.34 (3.38) 25 65923.37 (3.78) 24
60 19.60 (4.14) 2014321.58 (3.93) 2236924.43 (3.31) 2557323.20 (3.96) 23
5719.30 (3.79) 19113 20.89 (4.50) 21246 24.32 (3.04) 2541822.69 (4.12) 23
38 18.37 (3.87) 19 6720.57 (4.79) 21 12224.00 (3.35) 2422822.05 (4.48) 23
1416.07 (3.17) 17 2320.35 (4.91) 20 4223.60 (3.47) 24 7921.32 (4.78) 22
Total by education
230 20.55 (4.04) 2160822.34 (3.97) 231,30624.81 (3.20) 252,14823.65 (3.84) 24
Neurology 77September 27, 2011
when applying recommended cut scores, particularly
given the high failure rate on certain items in the
present sample. In addition, these results underscore
the need for more research on clinically useful cutoff
values for the MoCA, as well as the impact of demo-
graphic factors in interpreting results. The presented
norms based on a recent, large population-based
study will enable clinicians and researchers to evalu-
ate an individual’s MoCA performance with more
H. Rossetti: acquisition of data, analysis and interpretation of data, and
drafting of the manuscript. L. Lacritz: study concept and design, interpre-
tation of data, and revision of the manuscript for content. C.M. Cullum:
interpretation of data and revision of the manuscript for content. M. Weiner:
study supervision and coordination, revision of the manuscript for content
(including medical writing for content), and obtaining funding.
Dr. Rossetti, Dr. Lacritz, and Dr. Cullum report no disclosures. Dr.
Weiner receives publishing royalties for The American Psychiatric Publish-
ing Textbook of Alzheimer Disease and Other Dementias (American Psychi-
atric Publishing, Inc., 2009) and received royalties for the Texas
Functional Living Scale.
Received March 11, 2011. Accepted in final form May 31, 2011.
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Neurology 77 September 27, 2011
2011;77;1272-1275 Published Online before print September 14, 2011
Heidi C. Rossetti, Laura H. Lacritz, C. Munro Cullum, et al.
Normative data for the Montreal Cognitive Assessment (MoCA) in a
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