The Montreal Cognitive Assessment (MoCA) is superior to the Mini-Mental State Examination (MMSE) for the detection of vascular cognitive impairment after acute stroke
Introduction
Vascular Cognitive Impairment (VCI), comprising of Vascular Cognitive Impairment No Dementia (VCIND), Vascular Dementia (VaD) and mixed dementia, is a common consequence of ischemic stroke [1]. Most cases of post-stroke VCI are due to VCIND [2] with 46% of VCIND patients developing incident dementia over a 5-year period [3]. As VCIND patients with more severe impairment were found to be at higher risk of conversion to dementia compared to patients with less severe or no cognitive impairment (NCI) [4], early detection of cognitive deficits may facilitate intervention to prevent cognitive deterioration. The feasibility of cognitive screening in the subacute phase of stroke needs to be investigated as screening at the conventional 3 to 6 month period after stroke may be less practical.
The widely used Mini-Mental State Examination (MMSE) [5] was found to be inaccurate in screening post-stroke cognitive impairment as it was especially insensitive to complex cognitive deficits [6]. By comparison, the Montreal Cognitive Assessment (MoCA) has been designed to be sensitive to mild deficits [7], and may detect more cognitive abnormalities after the ischemic stroke or Transient Ischemic Attack (TIA), particularly in executive function, attention and delayed recall [8]. However, a comparison study of both screening tools for patients in the subacute phase of stroke is required.
Hence, the primary aim of the present study was to test the hypothesis that MoCA is more sensitive than MMSE for detecting cognitive impairment in a population of subacute stroke patients. The feasibility and the psychometric properties of MoCA (modified for Singaporean population) were also compared with MMSE for detecting vascular cognitive impairment.
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Participants
One hundred stroke patients (≥ 21 years old) admitted to the stroke neurology service at the National University Health System (NUHS) of Singapore were recruited. Eligible participants had an acute ischemic stroke or TIA within the preceding 14 days and stable clinical status within the preceding 24 h. Exclusion criteria for this study were major physical disability (modified Rankin Scale (mRS) > 4) [9], significant aphasia or dysarthria that impeded cognitive assessment (National Institute of
Results
Recruited patients were mostly Chinese (76%) and males (62%) with a mean age of 61.2 ± 11.3 years. 52% had a level of education of primary and below. Most patients (84%) had ischemic stroke presenting with low disability level (median mRS score = 2 and median NIHSS score = 2). The mean interval between stroke event and assessment was 4.2 ± 2.4 days. Most patients were classified as Small Artery Occlusion by the TOAST (50%) with a further 21.4% with Large Artery Atherosclerosis, 17.9% with Cardioembolism,
Discussion
The principal finding of this study is that the MMSE is less sensitive than the MoCA in detecting VCI after acute stroke. More patients were identified with cognitive impairment by the MoCA (n = 59) compared to MMSE (n = 43). Both the mean MoCA score and several MoCA subtest scores could significantly differentiate between all three cognitive screening test result groups and had good discriminating properties, while only the mean MMSE scores but none of MMSE subtest scores could do so. Finally, 18
Acknowledgements
The study is supported by a Centre Grant from the National Medical Research Council (NMRC/CG/NUHS/2010).
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