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Prediction of the MoCA and the MMSE in Out-patients

with the risks of cognitive impairment

Teresa Leung Occupational Therapist Prince of Wales Hospital

7th May, 2012

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Outline of Presentation

Introduction

Study Objectives, Methodology

Study Result

Service Triage for cognitive impaired

Cognitive rehabilitation Service flow

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Introduction Cognitive impairment has

become a growing concern for the elderly population in Hong Kong.

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Introduction

Early detection of cognitive impairment for timely intervention has been the updated trend in management of cognitive impairment for achieving better outcome.

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Introduction

Occupational Therapists are specialized in cognitive assessment and rehabilitation, and a high volume of outpatients are referred for this purpose.

MMSE

MoCA

DRS

Adas cog

CDAD

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Introduction Therefore, there is a

need for effective and efficient cognitive assessment to differentiate those

clients with risks of cognitive impairment,

thus enhancing an early protocol driven

intervention to take place.

Screening

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MMSE MoCA

Introduction

MMSE and MoCA are the two commonly used

screening assessment used by Occupational

Therapist for elderly with cognitive impairment

Comparison: MoCA vs MMSE MoCA MMSE

Visuoconstructional

skills

V

(3D)

V

(2D)

Executive function V

(trail making, verbal fluency,

verbal abstraction

X

Attention and

working memory

V V

Language V

(sentence repetition +

nomination)

V

(sentence repetition)

Short term memory V

(5 items)

V

(3 items)

Orientation V V

Registration V

(Not for scoring)

V

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Objectives To study the effectiveness of two commonly used assessments for cognitive screening: the MMSE and the MoCA (Hong Kong Version), in their predictive power for cognitive impairment.

To study the correlation between the total scores of the MMSE and the MoCA.

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Methodology • A convenience sample of patients referred for

cognitive assessment and screening in Occupational therapy out-patient department were reviewed for the scores obtained in the MMSE and the MoCA in the same visit.

• Those patients with only the MMSE score but no MoCA score were excluded for this study.

• A total of 232 patients were collected, age ranged from 32 to 94, educational level from illiterate to university graduates.

Age range (n) 32-94

Below 50 12

51-60 38

61-70 73

71-80 79

81-90 29

Above 90 1

Total 232

Data

Diagnosis (n) multiple diagnosis

for some subjects

MCI 8

Dementia 28

Memory or cognitive decline 64

Alcoholism 4

Stroke 18

DM 27

HT 21

Parkinson’s Disease 4

Orthopedic problem 8

Cardiac problem 10

Others 58

Total 250

Data

Valid N Mean Score (SD) or %

Range

MMSE

(total

score)

232

25.4 (4.3) 6-30

MoCA

(total

score)

232

21.4 (5.4)

3-30

Formal education (yrs)

142 6.0 (3.8) 0-16

Data

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Result

MMSE MoCA

MoCA=0.951(MMSE)

-0.07(Age)

MMSE=11.45+0.648

(MoCA).

Linear regression analysis was performed with the

MMSE total score, age, gender and education as

predictors of the MoCA total score.

Using the same method of regression analysis, the

MoCA total score was the only predictor of the MMSE

total score

MMSE

Positive Negative

MoCA Positive 38 71

Negative 0 123

The false positive and false negative values were counted for both tests for the whole sample

The false negative

of the MMSE in

detecting cognitive

impairment was

71/232=30.6%.

Result

There was no

participants detected to

be positive in the

MMSE but negative in

the MoCA

However, there were 71

cases who were cognitively

impaired according to the

MoCA but failed to be

positive in the MMSE,

Decision making tree for Cognitive Assessment flow

MMSE

MMSE:

Below cut off MoCA

MoCA MMSE:

Above cut off

Other Dementia

Assessment as indicated

Eg. Dementia Rating

Scale, CDAD, ADAS Cog

Other specific Cognitive Assessment as indicated

eg. RBMT, TEA, FAB

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September, 2011

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Improvement in Efficiency 245x 51% = 125 patients with MMSE score

under cut off, if we can skip MoCA for them,

Administration time for each MoCA assessment is around 30 mins

125 x 30mins = 3750mins

If the contact time for each outpatient cognitive screening is 45 mins

3750/45 = 83 patients contact time

83/245 = 34%

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Service for Elderly with cognitive impairment Mild cognitive impairment

MMSE – 28 to 30 (24%) MoCA – 19 to 25.2 ADL maintained at independent level

Moderate cognitive impairment

MMSE – 18 to 27 (32%) MoCA – 11.4 to 21 Associated functional impairment

Severe cognitive impairment

MMSE – <18 (44%) Associated functional impairment

Mild cognitive

Impairment

Moderate cognitive

Impairment

Severe cognitive Impairment

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Service for Elderly with cognitive impairment

Patients with mild cognitive impairment but ADL function maintained at

independent level

Computer cognitive training

Home Based

cognitive training

(by patient)

Group Therapy

Caregiver Training

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Service for Elderly with cognitive impairment

Patients with moderate cognitive impairment and ADL requires mild

assistance

Computer cognitive training

Home Based cognitive

training (by patient and caregivers)

Group Therapy

Care giver training on cognitive

training and ADL

facilitation techniques

Referral to NGO for

maintenance training

Behavioral management

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Service for Elderly with cognitive impairment

Patients with severe cognitive impairment and ADL requires constant moderate

assistance

Care giver training on home based

cognitive training,

community resources and

communication skills for people with cognitive impairment

Home environment

adaptation and aids

prescription

Referral to NGO for support service for

caring

Behavioral management

Continuum of Cognitive Rehabilitation Service flow

Behavioral

Management

Caregiver

training

Environmental Adaptation

and Aids prescription Computer

Cognitive Training

Group Therapy for

Self Management

and Social Engagement

Home Based

Cognitive Training

Moderate Cognitive

Impairment

Mild Cognitive

Impairment

Severe Cognitive

Impairment

Referral to NGO

for maintenance training

Referral to NGO

for caring support

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Computer Cognitive Training

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Computer Cognitive Training

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Group Therapy

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Environmental Adaptation

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Environmental

Adaptation

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Labels to remind on rooms location

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Labels on Switches

Labels for clothing

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Aids for Medication

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Aids for time and Appointment

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Aids for personal Information

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Safe Electrical Appliance

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Conclusions: Clients with the MMSE below cutoff may be skipped for MoCA assessment as no false positive has been identified in the MMSE and this can improve the service efficiency.

MoCA should be performed with those clients with the MMSE above cutoff as the

false negative of the MMSE in detecting cognitive

impairment was 30.6%.

The regression equation found can help in the

transformation of the total scores of two tests for

clinical and research use.

The effective use of MMSE and MoCA in detecting mild to

severe cognitive impairment can help us to choose

appropriate service regime for community dwelling elderly in an efficient and effective way.

Acknowledgement

Dr. Kenneth Fong

Associate Professor

Department of Rehabilitation

Sciences, Hong Kong Polytechnic

University

Mr. Frederick Au

Department Manager

Occupational Therapy Department,

Prince of Wales Hospital

Ms Connie Cheuk

Ms Cindy Wong

Ms Yan Leung

Ms Elvis Ng

Occupational Therapy Department,

Prince of Wales Hospital

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Thank You