Is the Montreal cognitive assessment culturally valid in a diverse geriatric primary care setting? Lessons from the Bronx

Abstract

BackgroundEfficacy and validity of the MoCA for cognitive screening in ethnoculturally and linguistically diverse settings is unclear. We sought to examine the utility and discriminative validity of the Spanish and English MoCA versions to identify cognitive impairment among diverse community‐dwelling older adults.MethodsParticipants aged ≥65 with cognitive concerns attending outpatient primary care in Bronx, NY, were recruited. MoCA and neuropsychological measures were administered in Spanish or English, and a neuropsychologist determined cognitive status (normal with subjective cognitive concerns [SCC], mild cognitive impairment [MCI], and dementia). One‐way ANOVA compared cognitive statuses. ROC analyses identified optimal MoCA cutpoints for discriminating possible cognitive impairment.ResultsThere were 231 participants, with mean age 73, 72% women, 43% Hispanic; 39% Black/African American; 113 (49%) completed testing in English and 118 (51%) in Spanish. Overall MoCA mean was 17.7 (SD = 4.3). Neuropsychological assessment identified 90 as cognitively normal/SCC, average MoCA 19.9 (SD = 4.1), 133 with MCI, average MoCA 16.6 (SD = 3.7), and 8 with dementia, average MoCA 10.6 (SD = 3.1). Mean English MoCA average was 18.6 (SD = 4.1) versus Spanish 16.7 (SD = 4.3). The published cutpoint ≤23 for MCI yielded a high false‐positive rate (79%). ROC analyses identified ≤18.5 as the score to identify MCI or dementia using the English MoCA (65% sensitivity; 77% specificity) and ≤16.5 for the Spanish MoCA (64% sensitivity;73% specificity) in this sample of older adults with cognitive concerns.ConclusionsCurrent MoCA cutpoints were inappropriately high in a culturally/linguistically diverse urban setting, leading to a high false‐positive rate. Lower Spanish and English MoCA cutpoints may improve diagnostic accuracy for identifying cognitive impairment in this group, highlighting the need for the creation and validation of accurate cognitive screeners for ethnoculturally and linguistically diverse older adults.

Non-literacy biased, culturally fair cognitive detection tool in primary care patients with cognitive concerns: a randomized controlled trial

“…A total of 1,042 participants (86.8%) completed 12 months of follow-up. There were no statistically significant group differences that the Montreal Cognitive Assessment (MoCA) test cutoff points for detecting dementia that were established in mostly white populations were too high in our US-based study sample that consisted of mostly Black or Hispanic people 16 . Black and Hispanic participants in the US-based Health and Retirement study were reported to have missed or delayed diagnosis of dementia more often compared to white people 17 .…”

“…Given that we enrolled only adults with cognitive concerns, the 5-Cog sensitivity and specificity is reasonable. In comparison, in the 5-Cog subsample that agreed to additional testing, we reported that the MoCA test (<17) had a sensitivity of 65% for English and 64% for Spanish versions, and specificity of 77% for English and 73% for Spanish versus the neuropsychologist's independent diagnosis of cognitive impairment 2,16 . Unlike cognitive assessments with higher stated sensitivity and specificity that were validated in samples with cognitively healthy controls 5,9,13 , test-negative cases in the 5-Cog arm were not cognitively normal as they had cognitive concerns 36 .…”

“…In the intervention arm, the 5-Cog battery had a sensitivity of 96% and specificity of 71% for PCP diagnoses of MCI or dementia, suggesting a low false-negative rate. In 295 participants in the 5-Cog arm who agreed to additional cognitive testing after seeing their PCP, the 5-Cog battery had a sensitivity of 70% and specificity of 71% for detecting MCI or dementia using a cutoff score of <17 on the MoCA test 2,16 .…”