What is the Montreal Cognitive Assessment (MoCA) and how is it scored?
Executive summary
The Montreal Cognitive Assessment (MoCA) is a brief, 10‑minute, 30‑point cognitive screening tool developed to detect mild cognitive impairment; higher scores mean better cognition and 26/30 is the commonly cited “normal” cut‑off (scores range 0–30) [1] [2]. Multiple studies and reviews warn that the 26 threshold can misclassify people across education, race and language groups and that local norms or adjusted cutoffs often perform better [3] [4].
1. What the MoCA is and why it exists — a targeted screen for early impairment
The MoCA was created to be a short, sensitive screen for mild cognitive impairment and early dementia when older tools like the MMSE missed subtle deficits; it samples seven cognitive domains including visuospatial/executive skills, attention, naming, language, abstraction, delayed recall and orientation and takes roughly ten minutes to administer [1] [5] [6].
2. How the test is structured — domains, items and scoring mechanics
The test combines brief tasks (trail‑type items, clock‑drawing, serial subtraction, memory recall, naming, language fluency and orientation) whose item subscores are summed into a single total; the total possible score is 30 and exam forms and manuals score individual items and add them to a total out of 30 [7] [1] [5].
3. The headline cutoff — 26/30 — and where it came from
Clinical guidance and many summaries present a total score of 26 or higher as “normal,” with lower scores suggesting possible cognitive impairment; that 26/30 threshold is widely quoted in review articles and clinician resources [2] [8] [6].
4. Why the 26 cut‑off is controversial — evidence of misclassification
Large, population‑based analyses and methodological critiques show the single 26 cut‑off misclassifies many people: in some community samples a majority scored below 26 despite no clinical diagnosis, and analyses recommend different thresholds by race and education because sensitivity/specificity vary substantially [9] [3] [4].
5. Adjustments and alternative norms — education, race, language and versions
Researchers and guideline authors advise adjusting interpretation for education (some recommend an extra point for ≤12 years of education) and establishing race/ethnicity‑ or language‑specific cutoffs; papers suggest cutoffs of ≤25 for White participants and ≤22 for Black participants in some cohorts, and other studies provide population norms by age and education [3] [4] [9].
6. Specialized versions and limitations — sensory and setting adaptations
Modified MoCA forms (telephone, visually reduced versions, and shorter subsets) exist for patients with hearing or vision loss and for remote screening; some adapted forms score out of fewer points and include conversion approaches back to a 30‑point scale, but sources caution conversion and new cutoffs must be validated locally [10] [8] [5].
7. What a given score usually means in practice — group averages and ranges
Studies report mean MoCA totals differing by diagnostic group: community participants without impairment averaged roughly 27–27.4 in some samples, people with mild cognitive impairment averaged in the low 20s, and Alzheimer’s disease groups averaged in the mid‑teens; nonetheless, population means shift with age, education and sampling method [2] [1] [11].
8. How clinicians should use the MoCA — screening, not diagnosis
Clinicians use the MoCA as a screening step that flags who needs fuller neuropsychological assessment; a score below a chosen cutoff prompts further workup, while a normal score does not by itself exclude future decline. Best practice is to interpret MoCA scores alongside clinical history, functional status and, where available, local normative data [1] [5] [4].
9. Hidden assumptions and agendas in reporting about the MoCA
Reports that emphasize a single universal cutoff favor simplicity and clinical throughput but risk overdiagnosis in underrepresented populations; conversely, research pushing multiple cutoffs stresses equity but complicates bedside use. Sources that promote a single cutoff often derive from initial validation cohorts and clinical convenience, whereas critiques come from population‑based and racially diverse datasets [2] [3] [4].
10. Bottom line for patients and caregivers
The MoCA is a validated, quick 30‑point screen widely used to detect early cognitive problems; 26/30 is the frequently cited “normal” threshold but available evidence shows that interpretation must be adjusted for age, education, language and race, and that the MoCA alone does not establish a diagnosis [1] [3] [4].
Limitations: available sources do not mention every country‑specific translated version or every operational detail of scoring rules; for implementation guidance consult the official MoCA manuals and local normative studies cited above [7] [9].