Validity of the Montreal Cognitive Assessment Screener in Adolescents and Young Adults With and Without Congenital Heart Disease

Abstract

Background Cognitive deficits are common, long-term sequelae in children and adolescents with congenital heart disease (CHD) who have undergone surgical palliation. However, there is a lack of a validated brief cognitive screening tool appropriate for the outpatient setting for adolescents with CHD. One candidate instrument is the Montreal Cognitive Assessment (MoCA) questionnaire. Objective The purpose of the research was to validate scores from the MoCA against the General Memory Index (GMI) of the Wide Range Assessment of Memory and Learning, 2nd Edition (WRAML2), a widely accepted measure of cognition/memory, in adolescents and young adults with CHD. Methods We administered the MoCA and the WRAML2 to 156 adolescents and young adults ages 14-21 (80 youth with CHD and 76 healthy controls who were gender and age matched). Spearman rank order correlations were used to assess concurrent validity. To assess construct validity, the Mann Whitney U-test was used to compare differences in scores in youth with CHD and the healthy control group. Receiver operating characteristic curves (ROC) were created and area under the curve, sensitivity, specificity, positive predictive value, and negative predictive value were also calculated. Results The MoCA median scores in the CHD versus healthy controls were (23 [range, 15-29] versus 28 [range, 22-30; p < .001]), respectively. With the screening cutoff scores at < 26 points for the MoCA and ≤ 85 for GMI (<1 SD, m = 100, SD = 15), the CHD versus healthy control groups showed sensitivity = .96 and specificity = .67 versus sensitivity = .75 and specificity = .90, respectively, in the detection of cognitive deficits. A cutoff score of 26 on the MoCA was optimal in the CHD group; a cutoff of 25 had similar properties except for a lower negative predictive value. The area under the ROC curve (95% CI) for the MoCA was 0.84 (95% CI [0.75, 0.93]; p = < .001) and 0.84 (95% CI [0.62, 1.00]; p = .02) for the CHD and controls, respectively. Discussion Scores on the MoCA were valid for screening to detect cognitive deficits in adolescents and young adults aged 14-21 with CHD when a cutoff score of 26 is used to differentiate youth with and without significant cognitive impairment. Future studies are needed in other adolescent disease groups with known cognitive deficits and healthy populations to explore the generalizability of validity of MoCA scores in adolescents and young adults.

Brain abnormalities in cognition, anxiety, and depression regulatory regions in adolescents with single ventricle heart disease

“…The maximum score on the MoCA can be 30, and a score < 26 is considered abnormal. The MoCA has been validated for use in adolescents with CHD (Pike et al, 2016).…”

“…Cognitive deficits, including memory and executive functions are well documented in over 60% SVHD adolescents (Cassidy, White, DeMaso, Newburger, & Bellinger, 2015;Gerstle et al, 2016;Pike et al, 2016).…”

“…Despite multiple reports of cognitive deficits, anxiety, and depression in complex SVHD, the underlying causes for these adverse symptoms remain unclear (Cohen et al, 2007;Moon et al, 2009;Pike et al, 2016). Preoperative brain injury has been identified in over 60% of newborns with SVHD, which may be explained in part by structural brain immaturity (Donofrio & Massaro, 2010;Marelli et al, 2016;Sethi et al, 2013).…”

Reduced brain mammillary body volumes and memory deficits in adolescents who have undergone the Fontan procedure

“…The WRAML2 consists of 6 subtests, involving verbal and visual memory and attention/ concentration, which yields the General Memory Index (GMI) score, and working memory, verbal and visual memory recognition, which produce the General Recognition Index (GRI) scores (normal, 100±15; ≤ 85 considered mild to moderate memory impairment). The alpha reliabilities for the core subtests range from 0.85-0.94 (16). The WRAML2-derived GMI score has been widely used to assess memory in the adolescent population both with and without CHD (14).…”

“…The total MoCA score ranges from 0-30, and a score <26 is considered abnormal. The MoCA has been validated in adolescents both with and without CHD and has a Cronbach's alpha of 0.8 (15,16).…”