MMSE vs. MoCA: What You Should Know

By Lindsey Getz

The Montreal Cognitive Assessment, used to evaluate cognitive abilities, can better discern some deficits than the Mini-Mental State Exam.

In the past, testing for Alzheimer’s disease and other cognitive issues often meant turning to the Mini-Mental State Exam (MMSE) before any further testing was undertaken. Created by renowned psychiatrist Marshal Folstein, MD, and introduced in 1975, the MMSE tests cognitive function by examining orientation, word recall, language abilities, attention and calculation, and visuospatial ability.

Today, the Montreal Cognitive Assessment (MoCA), a newer test created in 1996, is also available. Assessing many of the same areas as the MMSE, the MoCA is a little more in depth and includes tasks such as a clock-drawing test and a trail test (connecting the dots).

“The MoCA is newer to the scene and originally just looked at patients with milder forms of Alzheimer’s,” explains Stephanie Lessig, MD, an assistant clinical professor at UCSD Neurosciences and VA Medical Center, who was lead author on a comparative study examining the use of the MoCA vs. the MMSE in patients with Parkinson’s. “The MoCA has since gone on to be used for other diseases as well. It seems to be a little better at looking in depth at some of the deficits that the MMSE might not pick up. For instance, the MMSE has a heavy language component, but that’s not an area that tends to be as much a deficit [in the early stages] of conditions like Parkinson’s or other forms of dementia, so that’s where the MoCA comes in at being a little more sensitive.”

Lessig’s study found that the MoCA is more sensitive to subtle cognitive deficits in patients with Parkinson’s disease compared with the MMSE, though the MMSE is the more commonly used test.

Like any test, especially those assessing cognitive abilities, the thought of participating can make older adults anxious. Physicians say caretakers and other professionals can help put their patients at ease by stressing that these tests are only meant to help.

Similar But Different

Both the MMSE and the MoCA are routine cognitive screening tests rated on a 30-point scale. They are both brief, though the MMSE is a little shorter, taking about seven to eight minutes to administer. The MoCA takes approximately 10 to 12 minutes. Neither test is very detail oriented and both would likely be used only for initial screening.

Many memory clinics and neurologists administer both tests as well as a host of others. More pressed for time, an internist or a primary care physician would likely conduct only one—probably the MMSE—which would be periodically repeated to test for potential decline.

“That’s certainly fine as a composite measure over time, but the MMSE is relatively insensitive to mild disease,” says Roy Hamilton, MD, MS, an assistant professor of neurology at the University of Pennsylvania in Philadelphia. “Patients with only minor cognitive impairment may be overlooked if this is the principal screening tool used.”

Their varying degrees of sensitivity create the biggest difference and likely become the biggest factor for determining which one is used.

“For mild impairment, the MoCA is the better test,” says Abhay Moghekar, MBBS, an assistant professor of neurology at The Johns Hopkins University School of Medicine in Baltimore. “It’s the more sensitive of the two and also more difficult. So if a physician has a patient come in with minimal complaints and questions whether it’s affected him or her functionally, the physician would likely choose the MoCA. If a patient comes in and is clearly functionally impaired, there’s no need for that highly sensitive test.”

“The MoCA discriminates very well between normal cognition and mild impairment or dementia, but it’s too difficult for moderate to severe conditions,” says Barbara Messinger-Rapport, MD, PhD, director of the Center for Geriatric Medicine at the Cleveland Clinic. “The questions are harder, though it does have some of the same testing elements as MMSE, such as orientation to time, date, and place. And like the MMSE, MoCA also tests for recall, but instead of having to remember three items like you would on MMSE, you’re asked to remember five.”

“MoCA is noteworthy for being more sensitive and therefore able to pick up on things the MMSE might miss,” adds Hamilton. “It has been validated in patients who may not be currently demented but are at the risk of progressing and getting worse.”

Overall, the MMSE is likely a better test for more severe conditions, but Messinger-Rapport says there is a ceiling and floor effect to all tests. “The ceiling for MMSE is that a highly educated person may score well on the MMSE but not be able to recognize their grandchildren,” she says.

“It’s also important to note that the MMSE, and to a degree the MoCA, were not designed to be differential diagnostic tools for disambiguating between different types of cognitive conditions,” adds Hamilton. “On their own, screening measures like these are poor at determining if a patient has Alzheimer’s or a different degenerative disease, such as frontotemporal dementia. More testing would be required. For instance, when a patient comes to the Penn Memory Center, they’ll get the MoCA and the MMSE, but they’ll also get a much more extensive battery of testing. Without doing a variety of tests, some issues can be missed.”

Calming the Nerves

The idea of undergoing testing for possible cognitive impairment is often daunting to older patients, who may become nervous and worry that their anxiety will only make the results worse. But a certain amount of anxiety is ubiquitous to these tests, says Hamilton. “We do take that into account when they’re being completed and to some extent, this anxiety is built into the performance norms for the measures since just about everyone is nervous during these tests. We always reassure patients that this is not a pass-fail test,” he explains.

Messinger-Rapport makes an effort to reassure patients and says it’s common to find that they’re nervous prior to testing. While patients may actually try to “practice” at home by going through some of the test questions or try to memorize the answers, this effort will only skew the test by providing false results and could hurt the patient in the long run.

“These tests are meant to help us track a patient’s cognition over time and help them if there’s a need,” Messinger-Rapport explains. “We certainly don’t want patients to be uncomfortable. Getting an answer wrong or a low score does not mean a patient is stupid. We make sure they realize that.”     

Hamilton says patients should remember they wouldn’t be participating in the testing in the first place if they or a caregiver didn’t recognize there was some cause for concern. That’s what makes it important to complete these tests so the patient can receive help if it’s needed.

“I believe tests like this are a way to objectify and quantify something that is already a concern and complaint,” Hamilton says. “These patients wouldn’t be coming to the memory center if they didn’t have some sort of concern. So in a way, it’s that history that is the evidence of an issue. The test is only a way to translate those concerns into an objective language. Tests can be helpful in making a diagnosis, but it typically requires the patient or their loved ones noticing a problem in the first place. It’s only meant to help.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.