Journal of Alzheimer’s Disease 59 (2017) 893–901 893

DOI 10.3233/JAD-170203
IOS Press

The Montreal Cognitive Assessment:

Normative Data from a Large Swedish
Population-Based Cohort
Emma Borlanda,b,1 , Katarina Näggaa,1,∗ , Peter M. Nilssonc , Lennart Minthona , Erik D. Nilssona
and Sebastian Palmqvista,b,∗
a Department of Clinical Sciences, Clinical Memory Research Unit, Malmö, Lund University, Sweden
b Department of Neurology, Skåne University Hospital, Sweden
c Department of Clinical Sciences, Clinical Research Unit, Malmö, Lund University, Sweden

Accepted 25 May 2017

Abstract.
Background: The Montreal Cognitive Assessment (MoCA) has a high sensitivity for detecting cognitive dysfunction.
Swedish normative data does not exist and international norms are often derived from populations where cognitive impairment
has not been screened for and not been thoroughly assessed to exclude subjects with dementia or mild cognitive impairment.
Objective: To establish norms for MoCA and develop a regression-based norm calculator based on a large, well-examined
cohort.
Methods: MoCA was administered on 860 randomly selected elderly people from a population-based cohort from the EPIC
study. Cognitive dysfunction was screened for and further assessed at a memory clinic. After excluding cognitively impaired
participants, normative data was derived from 758 people, aged 65–85.
Results: MoCA cut-offs (–1 to –2 standard deviations) for cognitive impairment ranged from <25 to <21 for the lowest
educated and <26 to <24 for the highest educated, depending on age group. Significant predictors for MoCA score were age,
sex and level of education.
Conclusion: We present detailed normative MoCA data and cut-offs according to the DSM-5 criteria for cognitive impairment
based on a large population-based cohort of elderly individuals, screened and thoroughly investigated to rule out cognitive
impairment. Level of education, sex, and age should be taken in account when evaluating MoCA score, which is facilitated
by our online regression-based calculator that provide percentile and z-score for a subject’s MoCA score.

Keywords: Cognitively healthy elderly, excluding cognitively impaired, Montreal Cognitive Assessment, normative,
population-based, representative, Swedish

INTRODUCTION are expected to almost double every 20 years, to

65.7 million in 2030 and 115.4 million in 2050 [1].
Cognitive impairment is a growing problem in an There is a great need for early and correct diagnosis
aging population with increasing comorbidity. It has and treatment of cognitive impairment. To achieve
been estimated that 35.6 million people lived with this, cognitive tests for early and sensitive detec-
dementia worldwide in 2010, and these numbers tion is essential. Furthermore, it is important that
the tests are accessible and that the results are sim-
1 Theseauthors contributed equally to this work. ple to interpret. The Montreal Cognitive Assessment
∗ Correspondence to: Katarina Nägga and Sebastian Palmqvist, (MoCA) has increased in popularity for assessment
Clinical Memory Research Unit, Department of Clinical Sci-
ences, Malmö, Lund University, Sweden. E-mails: katarina.
of cognitive function, but the Mini-Mental State
[email protected] (K. Nägga); [email protected] Examination (MMSE) is still one of the most fre-
(S. Palmqvist). quently used cognitive screening tests, despite its

ISSN 1387-2877/17/$35.00 © 2017 – IOS Press and the authors. All rights reserved
This article is published online with Open Access and distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC 4.0).
894 E. Borland et al. / The Montreal Cognitive Assessment

significant limitations [2]. The MoCA, however, has Over 28,000 subjects completed a baseline exami-
a higher sensitivity and similar specificity compared nation consisting of a questionnaire, anthropometric
to the MMSE for diseases affecting cognition [3]. measurements, and dietary assessment, correspond-
Previous studies have shown that the MoCA is a ing to a participation rate of 40.8% of the eligible city
better screening method for cognitive impairment population [20]. The only exclusion criteria that were
due to Parkinson’s disease [4], stroke [5], chronic decided on beforehand were language problems and
obstructive pulmonary disease [6], heart failure [7], mental retardation that prevented responders from
diabetes mellitus with complications [8], and chronic answering the questionnaire [19]. From this cohort,
hemodialysis [9]. Despite its global popularity, nor- 6,103 individuals were randomly selected for further
mative data for the MoCA does not yet exist in examination, and between 2007–2012, there was a
Sweden. reinvestigation where 3,734 people participated [21,
The original validation study of the MoCA sug- 22]. By this time, participants were aged between
gested a cut-off value of ≥26 out of 30 points to differ 65–85. They were consecutively examined with cog-
healthy subjects from mild cognitive impairment nitive tests, initially the MMSE and A Quick Test
(MCI) and healthy subjects [3]. Studies thereafter, of Cognitive Speed (AQT) [23], but eventually the
however, have shown that lower thresholds are nec- MoCA was added to the screening. 860 consecutive
essary for optimal diagnostic accuracy of MoCA in people were examined with the MoCA together with
dementia, as many people incorrectly would be diag- the other cognitive tests.
nosed with cognitive impairment using the cut-off The initial questionnaire involved questions on
score of 26 [10]. education, smoking, comorbidities, and medications.
Cognitive impairment is typically investigated in Participants with common comorbidities, such as
adults over the age of 65. When interpreting cognitive high blood pressure and diabetes, were kept in the
assessments, it is important to have population-based study so that the normative sample would reflect a true
normative data suitable for the population on which it elderly population. There were three options for level
is being used. Several previous studies on normative of education: primary education/elementary school
data for the MoCA have included age groups below including up to 10 years of education; secondary
the average age of patients who are being assessed for school meaning high school including any additional
cognitive impairment (including participants below courses; and finally higher education such as a uni-
the age of 45) [11–15], and some studies have derived versity degree. Participants missing data on education
norms based on a relatively small normal population were asked for number of completed education years
[13, 16–18]. Hence, there is a need for normative data when assessed with the MoCA, and answers were
from a large population in a representative age group. transformed into education level.
Our aim was to generate normative data for the This study was approved by the regional ethi-
MoCA valid for Swedish population. We analyzed cal committee at Lund University, Lund, Sweden.
normative scores using data from 746 cogni- A written informed consent was obtained from all
tively healthy participants aged 65–85 years in a participants.
population-based study. We also investigated how
the variables age, sex, and level of education affect MoCA administration and scoring
MoCA scores. Moreover, we created a regression
model using the significant predictors, to be avail- The MoCA assesses global cognitive function and
able in an online calculator for physicians and other contains of 10 subtests. Visuospatial abilities are
professionals to assess cognitive impairment. assessed using a clock-drawing task and a three-
dimensional cube copy, short-term memory is tested
with two learning trials of five nouns followed by a
METHODS delayed recall task. Executive functions are assessed
using a task adapted from the Trail Making B test,
Study population and demographics a phonemic fluency task, and a two-item verbal
abstraction task. Attention, concentration, and work-
The participants were included from the prospec- ing memory are evaluated using an attention task, a
tive cohort Malmö Diet and Cancer Study [19], a serial subtraction task and digits forward and back-
part of the EPIC study. In the 1990s, 44–74-year-old ward. Language is tested with a naming task with
people living in Malmö were recruited for the study. low-familiarity animals (lion, camel, rhinoceros),
 E. Borland et al. / The Montreal Cognitive Assessment 895

repetition of two syntactically complex sentences, of the brain and in a majority of the cases analysis
and the fluency task. Orientation is evaluated by time of cerebrospinal fluid amyloid-beta 1–42, total tau,
and place [3]. The participants in our study were eval- and phosphorylated tau was also performed. Addi-
uated with the Swedish MoCA, version 7.0 (http:// tionally, they underwent neuropsychological testing
www.mocatest.org). Nurses and biomedical scien- with the animal and letter S fluency test, cube copy-
tists experienced in cognitive testing, administered ing, clock drawing, 10-wordlist of immediate and
the MoCA. In the original validation study [3], it was delayed recall from the Alzheimer’s Disease Assess-
suggested that people being evaluated with the MoCA ment Scale-cognitive (ADAS-cog), naming objects
received an extra point to the total score if they had from the ADAS-cog and Stroop test (Victorian ver-
≤12 years of education. We calculated mean MoCA sion). Subjects diagnosed with any type of mild or
scores without adding an extra point for low edu- major neurocognitive disorder (NCD) according to
cation. To increase the sample sizes of age groups, the DSM-5 criteria [29] were excluded from the nor-
larger age intervals were created with overlapping mative sample. Diagnosis was based on consensus
age groups according to a previously described decision by physicians experienced in dementia dis-
method [24], which has been used in other normative orders (S.P., K.N.). Participants not diagnosed with
studies [15]. cognitive impairment were re-entered into the nor-
mative population.
Screening and assessment of cognitive
impairment Statistical analysis

We screened for cognitive impairment with the Chi-square tests and the Mann-Whitney U test
MMSE and AQT. The MMSE assesses global cog- were used for group comparisons. The different fac-
nition with a well-established cut-off for cognitive tors’ impact on total MoCA score were analyzed
impairment at <24 points that provides a high speci- using linear regression and the factors sex, age, level
ficity [25, 26]. AQT, on the other hand, provides a of education, lipid lowering medication, cardiovas-
high sensitivity for impaired attention and executive cular medication, diabetes medication, and smoking
function [23, 27]. The test score constitutes the num- were entered separately in linear regression mod-
ber of seconds it takes to fulfil each test plate where els with MoCA as the dependent variable using a
the subject should name the color and form of 40 stepwise method. The association between the sig-
figures [23]. The cut-off for AQT was set at >90 s nificant covariates and the MoCA was tested using
for cognitive impairment (higher score equals poorer quadratic, cubic, and logarithmic models, and inter-
performance). This approximately corresponds to +1 action between variables was tested for. Finally, the
standard deviation (SD) based on a previous nor- significant covariates were entered into a multivariate
mative sample where the mean score was 71.2 s regression model with MoCA as the dependent vari-
(SD 21.5 s) [28]. The MMSE and AQT administered able. To calculate predicted z-scores and percentiles,
together improve sensitivity, and have a higher sensi- we used the intercept, the estimates, and the Root
tivity than MMSE in combination with Clock Draw- Mean Square Error (RMSE) from the final multi-
ing Test [28]. They are thus a suitable complement to variate regression model according to a previously
each other when evaluating cognitive function. published article [30]. A p-value less than 0.05 was
considered significant. For analysis of data we used
Extended examination to rule out cognitive SPSS (Released 2013. IBM SPSS Statistics for Mac-
impairment intosh, Version 22.0, NY: IBM Corp).

Participants who scored below 24 points on the RESULTS

MMSE, finished the AQT in over 90 s, or reported
symptoms of cognitive impairment, were summoned Enrollment
for a clinical investigation at the Memory Clinic of
Skåne University Hospital in Sweden. Here, they 134 of 860 individuals completed the AQT in over
were evaluated by physicians with special interest 90 s, scored below 24 on the MMSE, or reported
in cognitive disorders. Cases with a suspicion of symptoms of cognitive impairment, and were sum-
cognitive disorder underwent a thorough dementia moned for a clinical examination (Fig. 1). Out of
investigation. This included a computed tomography the 134 participants, 73 people declined proceed-
896 E. Borland et al. / The Montreal Cognitive Assessment

Fig. 1. Flow chart of the enrollment process. 860 people completed MoCA together with MMSE and AQT. 133 participants scored <24 on
MMSE, >90 on AQT or reported symptoms of cognitive impairment, and were summoned for a clinical investigation at the memory clinic.
31 of these 133 people were assessed as cognitively healthy and re-entered into the normative population and 102 were excluded according
to the flowchart.

ing with an examination and were excluded from the mean (SD) scores stratified on age group and edu-
study. Out of the 61 people examined, 18 were diag- cation level are shown in Table 2. The participants
nosed with MCI, 11 with dementia, and the remaining scored on average 82% on visuospatial function, 98%
32 were considered cognitively healthy and were on naming, 98% on attention letters, 97% on atten-
re-entered into the normative population. The final tion subtraction, 89% on attention digits, 93% on
normative group thus consisted of 758 people: 474 language repeat, 69% on language fluency, 85% on
women and 284 men. The mean age for women was abstraction, 62% on delayed recall, and 99% on ori-
73.3 (SD 5.2) and for men 72.7 (SD 5.0) (p = 0.133). entation. Normative scores for the different parts of
MoCA stratified according to age and education are
Socio-demographics provided in Supplementary Table 1. The mean MoCA
score for women was 26.1 (SD 2.3) and for men 25.7
The normative group and the excluded group, i.e., (SD 2.4) (p = 0.006). In Table 3, we present data of
cognitively impaired people or people who declined calculated cut-off scores ≤1, ≤1.5 and ≤2 SD below
a complementary examination, are described in the mean score.
Table 1. There was a significant difference in the
groups’ education level and mean age, which was Regression analysis
expected considering that low education and older
age both are risk factors for cognitive impairment. The variables sex, level of education, and age were
There was also a significant difference in the groups’ significantly associated with total MoCA score in
scores in MMSE, AQT, and MoCA, including every the univariate models as well as independent signif-
MoCA subtest. 37.3% of the normative group scored icant variables in the multivariate model (r = 0.334,
below the original cut-off value of 26 compared to r2 = 0.112) (Table 4). The results show female sex
78.4% of the excluded group. and higher level of education significantly correlating
with higher MoCA scores, and older age signifi-
MOCA scores cantly associating with lower scores. We did not find
stronger association between the significant variables
The mean MoCA score was 26.0 (SD 2.3) for with total MoCA score using logarithmic, quadratic
the entire normative population (ages 65–85). The or cubic models (data not shown). The other vari-
 E. Borland et al. / The Montreal Cognitive Assessment 897

Table 1
Demographics of the study population
Normative Excluded p-value
group group
Age (SD) 73.1 (5.1) 75.5 (5.7) <0.0001
Use of medication, n (%)
– Cardiovascular 409 (54.0) 41 (40.2) 0.266
– Anti-diabetes 60 (7.9) 12 (11.8) 0.188
– Lipid lowering 218 (28.8) 37 (36.3) 0.119
Education level (%) 0.002
– Primary school∗ 63.9 79.2
– Secondary school∗∗ 20.8 13.9
– Higher education∗∗∗ 15.3 6.9
Smoking (%) 0.665
– Yes, I smoke or have smoked 54.8 52.5
– No, I have never smoked 45.2 47.5
MMSE score, mean (SD) 27.9 (1.4) 24.9 (3.1) <0.0001
AQT score, mean (SD) 69.9 (13.1) 107.2 (29.8) <0.0001
MoCA total score, mean (SD) 26.0 (2.3) 21.6 (4.3) <0.0001
– Visuospatial/Executive abilities 4.1 (1.0) 2.9 (1.4) <0.0001
– Naming 2.9 (0.3) 2.7 (0.7) <0.0001
– Attention digits 1.8 (0.5) 1.4 (0.6) <0.0001
– Attention letters 1.0 (0.1) 0.9 (0.2) 0.007
– Attention subtraction 2.9 (0.3) 2.3 (1.0) <0.0001
– Language repeat 1.9 (0.4) 1.4 (0.8) <0.0001
– Language fluency 0.7 (0.5) 0.3 (0.5) <0.0001
– Abstraction 1.7 (0.6) 1.4 (0.8) <0.0001
– Delayed recall 3.1 (1.3) 2.3 (1.5) <0.0001
– Orientation 6.0 (0.2) 5.8 (0.6) 0.002
Abnormal MoCA score according 37.3 78.4 <0.0001
to original cut-off (<26), (%)
Total 758 102
∗ Elementary school or lower, up to 10 years of education. ∗∗ Graduation from high school/Advanced

level including any additional courses. ∗∗∗ University degree. SD, standard deviation. Bold p-values
are considered significant (<0.05).

Table 2 (standardized ␤ = 0.003, p = 0.934), or smoking (stan-

MoCA scores by age and education level dardized ␤ = –0.045, p = 0.209)]. We did not find a
Education level significant interaction between variables.
Age Primary Secondary Higher Total In the Supplementary Material, we present a
group school* school∗∗ education∗∗∗ by age
regression model for interpreting MoCA scores. The
65–75 25.8 (2.2) 26.7 (2.1) 27.1 (1.7) 26.3 (2.2)
n = 327 n = 112 n = 95 n = 534
model can be used for individuals being assessed
70–80 25.4 (2.3) 26.5 (2.2) 26.8 (1.7) 25.9 (2.3) for cognitive impairment, simply by inserting MoCA
n = 291 n = 79 n = 72 n = 442 score, gender (1 = female, 0 = male), level of edu-
75–85 24.9 (2.4) 26.0 (2.6) 26.5 (1.9) 25.3 (2.5) cation (1, 2, 3), and age. The result is shown as a
n = 184 n = 56 n = 28 n = 268
Total by 25.5 (2.3) 26.5 (2.3) 27.0 (1.8) 26.0 (2.3)
z-score, i.e., SD, and percentiles from the normative
education n = 484 n = 158 n = 116 n = 758 mean.
Scores are in mean (standard deviation). ∗ Elementary school or
lower, up to 10 years of education. ∗∗ Graduation from high school/
Advanced level including any additional courses. ∗∗∗ University
degree. 
ȲMoCA = 31.104 + 0.565S − 0.090A + 0.713E,

ables entered in the linear regression model did RMSE = 2.176

not show significant effect on total MoCA score S = sex (0=men,1=women) , A = age, E = level of
[lipid lowering medication (standardized ␤ = 0.037,
p = 0.338), cardiovascular medication (standard- education(1, 2, 3)
ized ␤ = –0.028, p = 0.476), diabetes medication
898 E. Borland et al. / The Montreal Cognitive Assessment

Table 3
Cut-off scores by age and education level
Education level
Age group SD below mean Primary Secondary Higher
school∗ school∗∗ education∗∗∗
65–75 ≤1
≤1.5
≤2

70–80 ≤1
≤1.5
≤2

75–85 ≤1
≤1.5
≤2

Raw MoCA-scores not including an extra point for low education. Arrows show cut-offs at –1 SD
(yellow), –1.5 SD (orange), and –2 SD (red) below the mean MoCA score. The cut-offs correspond
to the DSM-5 criteria where major neurocognitive disorders s typically perform ≥2 SD below
appropriate norms, and mild neurocognitive disorders typically perform in the 1-2 SD range. Cut-
offs are preferably chosen in the age group where age is centered midmost in the age interval.
∗ Elementary school or lower, up to 10 years of education. ∗∗ Graduation from high school/Advanced

level including any additional courses. ∗∗∗ University degree. SD, standard deviation.

Table 4 of our normative population would have been incor-

Significant predictors of MoCA score in the multivariate regression rectly interpreted as cognitively impaired according
model
to our evaluation of the population. The mean score of
Standardized Unstandardized p-value
26.0 (SD 2.3) was 1.0–4.2 points higher than in other
beta beta
normative studies [13–17, 31–33], though lower than
Sex 0.119 0.565 0.001
Age –0.201 –0.90 <0.0001 the average score of 27 for cognitively normal par-
Education level 0.231 0.713 <0.0001 ticipants in the small original study (n = 90 healthy
All three variables were also significant in univariate models. elderly controls). The very large normative study
Non-significant co-variates were use of anti-diabetes medication, using data from the Dallas Heart Study (n = 2,653)
cardiovascular drugs or lipid-lowering drugs, as well as smoking. included participants aged 18–85 [15]. They pre-
The intercept of the model was 31.104 and the root mean square
sented a mean score of only 23.4 (SD 4.0) despite
error (RMSE) was 2.176.
a high mean education (13 years) and low mean age
(50 years). In the age groups closest corresponding
DISCUSSION to our study (65–80 years), the mean scores were
16–24 points depending on education level, com-
We present normative scores for the MoCA from pared with 25–27 points in our study. Considering
a large cognitively healthy Swedish population- their low mean scores and that no other tests for cog-
based cohort of 758 elderly individuals aged 65–85 nitive impairment were conducted, we conclude their
years. We found that higher level of education study included people with cognitive impairment. It
and female sex were independently associated with is also possible socio-cultural background may play
higher MoCA scores, and older age with lower scores. a role in the study considering the study consisted
Using the cut-off score from the original study, 37.3% of ethnically diverse subjects. The largest normative
 E. Borland et al. / The Montreal Cognitive Assessment 899

study we found (n = 5,802) from the TILDA study [12]. That study included participants from the age
presented mean scores for the age of 65 between of 41, and participants were not physician-evaluated
23.1–26.3 depending on education level, compared to exclude people with cognitive impairment. Using
to 25.8–27.1 in our youngest group. At the age of 85, their suggested model on our population shows their
scores ranged 19.3–23.9 compared to 24.9–26.5 in equation does not fit an elderly population such as
our oldest group, given of course our groups include ours. Giving an example of an 85-year-old woman
larger age groups. The reason why we have found with 17 years of education (corresponding to educa-
higher scores than in most other studies is probably tion level 3), the previous equation would calculate
because we have more thoroughly screened out peo- an expected score of 31.5, compared to 26.2 with
ple with cognitive impairment, deriving a sample of our model. Considering 31.5 is above maximum
truly cognitively healthy elderly. However, we do not score, and well-educated elderly are a growing pop-
believe that our population consists of “super normal” ulation, we claim our regression model to be more
participants since we did not just use an automated versatile.
algorithm to screen out subjects. The participants who A shortcoming of the study is the small amount of
were screened out, were then assessed at a memory individuals in the oldest age group with a university
clinic (some using longitudinal follow-up visits), and degree (n = 28), which in the future in an aging pop-
re-entered into the normative sample if not diagnosed ulation will be more common. On the other hand, the
with MCI, dementia, or any type of neurodegenera- elderly of today mostly have a low education and in
tive disease. this norm group we had a large subsample (n = 184)
Consistent with previous findings, older age was compared to the largest normative study (n = 2,653)
associated with lower scores [11–18, 31–35]. We where their corresponding norm group (70–80 years
found a 1.0-point difference between the youngest old, <12 years of education) only consisted of 14 par-
(65–75) and oldest (75–85) groups; other studies ticipants. This highlights a strength of the present
have reported a difference of 0.6–2.4 points between study, which is that we have used a large suitable
similar age groups [13, 15–17, 31]. Lower level of age group of elderly people, corresponding to the
education was significantly associated with lower typical patient group being assessed for cognitive
scores, correlating with results from other studies impairment.
[11–18, 31–35]. The difference in mean score was In DSM-5, performance of neuropsychological
1.4 points between the least and highest educated testing for neurocognitive disorders is suggested
groups, in agreement with the original suggested for major neurocognitive disorder (corresponding to
method of adding an extra point for low educa- dementia level) as 2 SD below appropriate norms,
tion (≤12 years). Gender was significantly associated and for mild neurocognitive disorder (corresponding
with MoCA score, with a mean for men of 0.45 to MCI level) performance typically lies in the 1-2 SD
points below the mean for women. This is consistent range below a normative mean [29]. Based on these
with a Greek normative study showing a difference guidelines, appropriate cut-offs stratified on age and
in mean of 0.3 points between sexes [11]. In a education are presented in Table 3. When interpret-
study by Larouche et al., in which mean scores were ing an individual’s score, the ≤–2 SD cut-off should
not presented, male sex was also a negative predic- be considered a clear cognitive impairment, while
tive factor in their regression model [12]. The Irish a score of ≤–1 SD is just indicative of cognitive
study by Kenny et al. also found differences between impairment and these individuals should be further
men and women were statistically significant, how- examined or followed longitudinally to ensure the
ever, relatively minor why they chose not to stratify diagnosis. In a clinical situation, there are of course
after sex [35]. Given the effects of age, education, many other reasons besides cognitive impairment that
and gender, a sharp cut-off point as suggested in can explain a low score (language difficulties, cultural
the original MoCA study [3] is not as optimal as differences, motivation, etc.). Because of the over-
when all factors are taken into account to evaluate lapping age groups in Table 3, the group where age
the result. In the multivariate regression model, we is midmost in age intervals should be selected. To
found that the effect sizes of age and education on account for all significant predictors of MoCA score
MoCA scores were similar and twice that of gender (age, education, and gender) as well as the exact
(standardized betas of –0.20 and 0.23, respectively, age of the patient, we instead recommend using the
compared with 0.12). We have only found one pre- regression-based calculator in the online supplement.
viously presented regression model for the MoCA This regression-based approach has also been shown
900 E. Borland et al. / The Montreal Cognitive Assessment

to give a more accurate classification of cognitive in Parkinson’s disease and dementia with Lewy bodies:
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