Open Access Maced J Med Sci electronic publication ahead of print,

published on November 25, 2017 as https://doi.org/10.3889/oamjms.2017.202

ID Design 2012/DOOEL Skopje, Republic of Macedonia

Open Access Macedonian Journal of Medical Sciences.
https://doi.org/10.3889/oamjms.2017.202
eISSN: 1857-9655
Clinical Science

Correlation between the Montreal Cognitive Assessment-

Indonesian Version (Moca-INA) and the Mini-Mental State
Examination (MMSE) in Elderly

*
Aldy Safruddin Rambe , Fasihah Irfani Fitri

Department of Neurology, Faculty of Medicine, Universitas Sumatera Utara, Indonesia

Abstract
Citation: Rambe AS, Fitri FI. Correlation between the BACKGROUND: As the rapid growth of the elderly population and the increased prevalence of Alezheimer’s
Montreal Cognitive Assessment-Indonesian Version
(Moca-INA) and the Mini-Mental State Examination Disease and related disorders, there is an increasing need for effective cognitive screening. The Mini Mental State
(MMSE) in Elderly. Open Access Maced J Med Sci. Examination (MMSE) is the most frequently used screening test of cognitive impairment because of its
https://doi.org/10.3889/oamjms.2017.202
convenience. The Montreal Cognitive Assessment-Indonesian Version (MoCA-INA) has been validated and
Keywords: MMSE; MoCA-INA; Cognitive screening;
Elderly.
recently been used as a cognitive screening tool.
*Correspondence: Aldy Safruddin Rambe, University of OBJECTIVES: The aim of this study was to compare the MMSE and MoCA-INA scores and to determine the
Sumatera Utara, Medan, North Sumatera, Indonesia. E-
mail: [email protected] correlation between the MMSE and MoCA-INA scores in elderly.
Received: 21-Aug-2017; Revised: 24-Sep-2017;
Accepted: 28-Sep-2017; Online first: 25-Nov-2017 MATERIAL AND METHODS: This was a cross-sectional study including 83 elderly subjects from November 2016
Copyright: © 2017 Aldy Safruddin Rambe, Fasihah Irfani until June 2017. We performed MMSE and MoCA-INA for assessment of cognitive function and the time between
Fitri. This is an open-access article distributed under the each test was at least 30 minutes.
terms of the Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC RESULTS: The study included 83 subjects which were consisted of 46 (55.4%) males and 37 (44.6%) females.
4.0).
The mean age was 69.19 ± 4.23 ranging from 65 to 79 years old. The average MMSE scores was 24.96 ± 3.38
Funding: This research did not receive any financial
support. (range 14 to 30). The average MoCA-INA scores was 21.06 ± 4.56 (range 5 to 30). The Pearson correlation
Competing Interests: The authors have declared that no coefficient between the scores was 0.71 (p<0.005). There were no significant differences of both scores based on
competing interests exist. history of hypertension, diabetes mellitus and previous stroke, but there was a significant difference in MMSE
scores based on level of education.
CONCLUSION: The MoCA-INA score showed a good correlation with the MMSE score. Both tests showed
comparable results but MoCA-INA showed lower average with wider range of scores.

Introduction economic impact of AD has led to a pressing need to

prevent or slow disease onset and progression, and
recent research efforts have focused on the
As our population grows older, the issue of transitional period from normal cognitive aging to
screening for dementia and cognitive impairment will dementia. This transition period, namely mild cognitive
become increasingly important because of the impairment (MCI), is signified by a measurable
increase incidence of Alzheimer’s disease (AD) and deterioration in cognitive function that is greater than
related disorders. Improvements in survival rates expected based on an individual’s age and education
following stroke will also increase the incidence of but which has not meaningfully affected a person’s
vascular and post-stroke cognitive impairment, as daily functioning [2, 3].
approximately 30% of stroke survivors will develop a Mild cognitive impairment is common in
progressive dementia [1]. elderly patients and can impact on prognosis and
Alzheimer’s disease (AD) is a chronic, quality of life. The areas of cognitive impairment that
debilitating condition causing significant disease occur at this stage primarily involve attention, verbal
burden and mortality in elderly. The health and fluency, executive function and visuo-spatial skills,
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which differs from the language and memory skills correlation between MMSE and MoCA-INA Scores
that are commonly associated with dementia [5]. was measured using the Pearson correlation. Both
scores were also compared based on level of
Cognitive screening tools in the elderly are
education. The study was performed with approval
important for the purpose of identifying the presence
obtained from the Health Research Ethical Committee
of cognitive impairment. Neuropsychological testing is
Medical Faculty of Universitas Sumatera Utara/H.
the gold-standard for assessing dementia and
Adam Malik General Hospital.
cognitive impairment, but it is time-consuming and
requires highly trained assessors. The Mini Mental
State Examination (MMSE) is the most frequently
used screening test of cognitive impairmens of AD [5],
mainly because of its convenience but not sensitive, Results
as it is influenced by age, socio-economic status and
level of education. It assesses primarily language and
memory skills and has been found to be insensitive to A total of 83 subjects were studied. The
detecting mild cognitive impairment [4]. Cognitive average age of subjects was 69.19 years old, ranging
performance as measured by the MMSE varies within from 65 to 79 years old. There were 46 (55.4%) males
the normal population by age and education [6]. The and 37 (44.6%) females. Most of the subjects had
Montreal Cognitive Assessment (MoCA), has been level of education of high school (43 subjects, 51.8%).
developed as a brief cognitive screening tool to detect There were 26 subjects (31.3 %) with history of
mild-moderate cognitive impairment. It has been hypertension, 17 (20.5%) with Diabetes Mellitus and
found to have high sensitivity and specificity for the 11 subjects (13.3%) with history of previous stroke.
detection of mild cognitive impairment [4, 7]. The The demographic characteristics are shown in Table
MoCA assess several cognitive domains including 1.
executive fuction, visuospatial function, attention and
Table 1: Demographic characteristics
concentration, memory, languange, calculation and
orientation [7]. The Indonesian version of MoCA, Characteristic Number (%) (n = 83)
Sex
namely MoCA-INA has been developed and validated Male 46 (55.4)
Female 37 (44.6)
in Indonesia and so it can be used as a cognitive Age,mean ± SD, years 69.19 ± 4.23
screening tool [8]. The aim of this study was to Age group, years
65-69 53 (63.9)
compare the MMSE and MoCA-INA scores and to 70-74 18 (21.7)
75-79 12 (14.5)
determine the correlation between the MMSE and Occupation
MoCA-INA scores in elderly subjects. Employee 16 (19.3)
Housewive 20 (24.1)
Entrepreneur 13 (15.7)
Farmer 4 (4.8)
Unemployed 30 (36.1)
Level of education
Elementary School 15 (11.3)
Junior High school 19 (14.3)
Method High School 63 (47.4)
College/University 36 (27.1)
History of Diabetes Mellitus
Yes 17 (20.5)
No 66 (79.5)
History of Hypertension
This was a cross sectional study involving 83 Yes 26 (31.3)
subjects which were recruited from the Memory Clinic No 57 (68.7)
History of Previous Stroke
Neurology Department Adam Malik General Hospital Yes 11 (13.3)
No 72 (86.7)
Medan North Sumatera Indonesia, between MMSE
November 2016 and June 2017. Inclusion criteria < 24 31 (37.3)
≥ 24 52 (62.7)
were age more than 65 years-old, compos mentis and Moca-INA Score
< 26 71 (85.5)
fully cooperative, speak Bahasa Indonesia fluently, ≥ 26 12 (14.5)
able to read and write, and gave written consent to be
included in the study. Subjects who were medically
unstable (delirium) or other psychiatric disorders, had The average MMSE score was 24.96 ± 3.38
an aphasia were excluded from the study. All subjects (range 14 to 30). The average MoCA-INA score was
underwent physical and neurologic examination and 21.06 ± 4.56 (range 5 to 30). Both scores showed
cognitive assessment including Mini Mental State comparable result but MoCA-INA showed lower
Examination (MMSE) and Montreal Cognitive average and a broader range of scores. Comparison
Assessment-Indonesian Version (MoCA-INA). The between the MMSE and MoCA-INA Score is shown in
time between each test was at least 30 minutes. Table 2.
Demographic information was collected including age,
Table 2: Comparisan between the MMSE and MoCA-INA Score
sex, occupation, level of education, history of stroke,
hypertension and diabetes mellitus. The MMSE and Score Mean SD Median Range
MMSE 24.96 3.38 25 14-30
MoCA-INA Scores were obtained. All statistical Moca-INA 21.06 4.56 21 5-30
procedures were performed with SPSS. The
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 Rambe & Fitri. Montreal Cognitive Assessment-Indonesian Version and the Mini-Mental State Examination in Elderly
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The Pearson’s correlation coefficient between lower average with wider range of scores. This finding
the scores was 0.71 (p < 0.005). A graph showing the has also been observed in a study by Ohta et al which
comparison between the MMSE and MoCA-INA compared Japanese version of MMSE and MoCA
scores based on age groups is shown in Figure 1. scores in 304 patients with Parkinson’s disease. They
There were no significant differences of both scores found the MMSE and MoCA scores were 26.3 ± 3.6
based on history of hypertension, diabetes mellitus (range 12-30) and 20.9 ± 5.0 (range 5-30),
and previous stroke, but there was a significant respectively [9]. A study by Aggarwal et al also found
difference in MMSE scores based on level of lower MoCA score (22.2 ± 5.1) if compared with
education, but not in MoCA-INA score (Table 3). MMSE (26.5 ± 3.5) [4].
This finding reflects the MoCA-INA as a more
challenging test that includes executive function,
higher level languange and complex visuospatial
processing that enable it to detect mild impairment or
certain domain of cognitive function, if compared to
MMSE. The MMSE has both a ‘ceiling’ and ‘floor’
effect: a score of 30 does not always mean normal
cognitive function and a score of zero does not mean
an absolute absence of cognition. It does not contain
much capacity to test frontal/executive or viusospasial
(typically right parietal) functions. The pentagon task
of the MMSE simply requires the patient to copy the
image and does not assess planning skills [10].
This is in line with several previous studies
that compared the MMSE and MoCA as cognitive
screening tool in differentiating dementia from MCI
Figure 1: A graph showing the comparison between the MMSE and
and normal cognitive aging. A study conducted by
MoCA scores based on age groups Roalf et al in 321 AD patients, 126 MCI and 140
healthy controls found that the MoCA is superior to
the MMSE as a global assessment tool, particularly in
One-way ANOVA. *Post-hoc LSD: elementary discerning earlier stages of cognitive decline. In
vs. high school p = 0.003; high school vs. college p = addition, the author found that overall diagnostic
0.015. accuracy improved when the MMSE or MoCA was
Table 2: Comparison between the MMSE and MoCA-INA Score
combined with an informant-based functional measure
[2]. In a study involving 219 healthy control, 299 MCI
MMSE Score MoCA-INA Score
Level of Education
Mean SD P Mean SD p and 100 AD cases, in which the author analyzed the
Elementary 21.40 2.96 16.60 5.12 relationship between the MoCA and MMSE scores, it
Junior High School 24.67 3.36 22.00 3.24
High School 26.00 2.94
0.007*
21.42 4.83
0.133 was found that both tools were more similar for
College/University 23.96 3.58 20.87 4.24 dementia cases, but MoCA distributed MCI cases
One-way ANOVA; *Post-hoc LSD: elementary vs high school p = 0.003; high school vs
college p = 0.015. across a broader score range with less ceiling effect
[11]. The MOCA is a useful brief screening tool for the
detection of mild dementia or MCI. With a cut-off
score of 26, the MMSE had a sensitivity of 17% to
detect subjects with MCI, whereas the MoCA detected
83% [12]. The MoCA showed a high sensitivity (0.94)
Discussion compared to MMSE (0.66) in detecting post stroke
cognitive impairment [13].
This study found the differences in MMSE
As the rapid growth of the elderly population score based on level of education, while the MoCA-
and the increased prevalence of AD and related INA did not show any significant difference. This
disorders, there is an increasing need for effective finding could also support the superiority of MoCA-INA
cognitive screening. This study compared the MMSE than MMMSE. MoCA has also been found to be
and MoCA-INA scores as cognitive screening tools. superior to MMSE in assessing cognitive impairment
The Indonesian version of MoCA has been validated in several other conditions. Wong et al carried out a
and said to be applicable for assessment of cognitive prospective onservational and diagnostic accuracy
function. There are several adjusments of MoCA-INA study on aneurysmal subarachnoid hemorrhage, The
compared to the original version in assessment of MoCA and MMSE were administered 2-4 weeks and 1
naming, memory and delayed recall and language year after ictus. They found that both tools were
function because of transcultural validation [8]. The succesful in differentiating between patients with and
results showed that The MoCA-INA and MMSE without cognitive impairment but at 1 year post-ictus,
showed comparable results but MoCA-INA showed the MoCA produced higher area under the curve

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