The Montreal Cognitive Assessment (MoCA): updated norms and psychometric insights into adaptive testing from healthy individuals in Northern Italy

Edoardo Nicolò Aiello, Chiara Gramegna, Antonella Esposito, Valentina Gazzaniga, Stefano Zago, Teresa Difonzo, Ottavia Maddaluno, Ildebrando Appollonio, Nadia Bolognini, Edoardo Nicolò Aiello, Chiara Gramegna, Antonella Esposito, Valentina Gazzaniga, Stefano Zago, Teresa Difonzo, Ottavia Maddaluno, Ildebrando Appollonio, Nadia Bolognini

Abstract

Background: The availability of fine-grained, culture-specific psychometric outcomes can favor the interpretation of scores of the Montreal Cognitive Assessment (MoCA), the most frequently used instrument to screen for mild cognitive dysfunctions in both instrumental and non-instrumental domains. This study thus aimed at providing: (i) updated, region-specific norms for the Italian MoCA, by also (ii) comparing them to pre-existing ones with higher geographical coverage; (iii) information on sensitivity and discriminative capability at the item level.

Methods: Five hundred and seventy nine healthy individuals from Northern Italy (208 males, 371 females; age: 63.4 ± 15, 21-96; education: 11.3 ± 4.6, 1-25) were administered the MoCA. Item Response Theory (IRT) was adopted to assess item difficulty and discrimination. Normative values were derived by means of the Equivalent Scores (ESs) method, applied to the MoCA and its sub-scales. Average ESs were also computed. Agreement with previous ESs classification was assessed via Cohen's k.

Results: Age and education significantly predicted all MoCA measures except for Orientation, which was related to age only. No sex differences were detected when tested along with age and education. Substantial disagreements with previous ESs classifications were detected. Several items proved to be scarcely sensitive, especially the place item from Orientation and the letter detection task. Memory items showed high discriminative capability, along with certain items assessing executive functions and orientation.

Discussion: Item-level information herewith provided for the Italian MoCA can help interpret its scores by Italian practitioners. Italian practitioners should consider an adaptive use of region-specific norms for the MoCA.

Keywords: Adaptive testing; Cognitive impairment; Cultural differences; Item Response Theory; Montreal Cognitive Assessment; Normative data.

Conflict of interest statement

The authors declare no known conflicts of interests.

© 2021. The Author(s).

References

    1. Mitrushina M. Cognitive screening methods. In: Grant I, Adams KM, editors. Neuropsychological Assessment of Neuropsychiatric and Neuromedical Disorders. Oxford University Press; 2009. pp. 101–126.
    1. Tsoi KK, Chan JY, Hirai HW, Wong SY, Kwok TC. Cognitive tests to detect dementia: a systematic review and meta-analysis. JAMA Intern Med. 2015;175:1450–1458.
    1. Trzepacz PT, Hochstetler H, Wang S, Walker B, Saykin AJ. Relationship between the Montreal Cognitive Assessment and Mini-mental State Examination for assessment of mild cognitive impairment in older adults. BMC Geriatr. 2015;15:1–9.
    1. Trevethan R. Sensitivity, specificity, and predictive values: foundations, pliabilities, and pitfalls in research and practice. Front Public Health. 2017;5:307.
    1. Willmes K (2010) The methodological and statistical foundations of neuropsychological assessment. In: Gurd J, Kischka U, Marshall J (eds) The Handbook of Clinical Neuropsychology, 2nd edn, Oxford University Press, New York, pp 28–49
    1. Bilder RM, Reise SP. Neuropsychological tests of the future: how do we get there from here? Clin Neuropsychol. 2019;33:220–245.
    1. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695–699.
    1. Julayanont P, Nasreddine ZS. Montreal Cognitive Assessment (MoCA): concept and clinical review. In: Larner AJ, editor. Cognitive Screening Instruments. Springer; 2017. pp. 139–195.
    1. Conti S, Bonazzi S, Laiacona M, Masina M, Coralli MV. Montreal Cognitive Assessment (MoCA)-Italian version: regression based norms and equivalent scores. Neurol Sci. 2015;36:209–214.
    1. Santangelo G, Siciliano M, Pedone R, Vitale C, Falco F, Bisogno R, Siano P, Barone P, Grossi D, Santangelo F, Trojano L. Normative data for the Montreal Cognitive Assessment in an Italian population sample. Neurol Sci. 2015;36:585–591.
    1. Bosco A, Spano G, Caffò AO, Lopez A, Grattagliano I, Saracino G, Pinto K, Hoogeveen F, Lancioni GE. Italians do it worse. Montreal Cognitive Assessment (MoCA) optimal cut-off scores for people with probable Alzheimer’s disease and with probable cognitive impairment. Aging Clin Exp Res. 2017;29:1113–1120.
    1. Siciliano M, Chiorri C, Passaniti C et al (2019) Comparison of alternate and original forms of the Montreal Cognitive Assessment (MoCA): an Italian normative study. Neurol Sci 40:691–702
    1. Moafmashhadi P, Koski L. Limitations for interpreting failure on individual subtests of the Montreal Cognitive Assessment. J Geriatr Psychiatry Neurol. 2013;26:19–28.
    1. Cecato JF, Martinelli JE, Izbicki R, Yassuda MS, Aprahamian I. A subtest analysis of the Montreal cognitive assessment (MoCA): which subtests can best discriminate between healthy controls, mild cognitive impairment and Alzheimer's disease? Int Psychogeriatr. 2016;28:825.
    1. Lord FM. The self-scoring flexilevel test 1. J Educ Meas. 1971;8:147–151.
    1. Thomas ML. The value of item response theory in clinical assessment: a review. Assessment. 2011;18:291–307.
    1. Baylor C, Hula W, Donovan NJ, Doyle PJ, Kendall D, Yorkston K. An introduction to item response theory and Rasch models for speech-language pathologists. Am J Speech Lang Pathol. 2011;20:243–259.
    1. Tsai CF, Lee WJ, Wang SJ, Shia BC, Nasreddine Z, Fuh JL. Psychometrics of the Montreal Cognitive Assessment (MoCA) and its subscales: validation of the Taiwanese version of the MoCA and an item response theory analysis. Int Psychogeriatr. 2012;24:651.
    1. Zheng L, Teng EL, Varma R, Mack WJ, Mungas D, Lu PH, Chui HC. Chinese-language Montreal Cognitive Assessment for Cantonese or Mandarin speakers: age, education, and gender effects. Int J Alzheimer’s Dis. 2012;2012:10.
    1. Freitas S, Prieto G, Simões MR, Santana I. Psychometric properties of the Montreal Cognitive Assessment (MoCA): an analysis using the Rasch model. Clin Neuropsychol. 2014;28:65–83.
    1. Luo H, Andersson B, Tang JY, Wong GH. Applying item response theory analysis to the Montreal Cognitive Assessment in a low-education older population. Assessment. 2020;27:1416–1428.
    1. Pedraza O, Mungas D. Measurement in cross-cultural neuropsychology. Neuropsychol Rev. 2008;18:184–193.
    1. Manly JJ. Critical issues in cultural neuropsychology: Profit from diversity. Neuropsychol Rev. 2008;18:179.
    1. Uysal-Bozkir Ö, Parlevliet JL, de Rooij SE (2013) Insufficient cross-cultural adaptations and psychometric properties for many translated health assessment scales: a systematic review. J Clin Epidemiol 66:608–618
    1. Siciliano M, Chiorri C, Battini V et al (2019) Regression-based normative data and equivalent scores for Trail Making Test (TMT): an updated Italian normative study. Neurol Sci 40:469–477
    1. Pirani A, Tulipani C, Neri M (2006) Montreal Cognitive Assessment, Italian version
    1. Ghasemi A, Zahediasl S. Normality tests for statistical analysis: a guide for non-statisticians. Int J Endocrinol Metab. 2012;10:486.
    1. Kim HY. Statistical notes for clinical researchers: assessing normal distribution (2) using skewness and kurtosis. Restorative Dentistry Endodontics. 2013;38:52–54.
    1. Rizopoulos D. ltm: An R package for latent variable modelling and item response theory analyses. J Stat Softw. 2006;17:1–25.
    1. Hambleton RK, Swaminathan H, Rogers HJ. Fundamentals of item response theory. California: Sage Publications; 1991. pp. 7–31.
    1. Baker FB, Kim SH. The basics of item response theory using R. New York: Springer; 2017. pp. 17–34.
    1. Spinnler H, Tognoni G. Standardizzazione e taratura italiana di test neuropsicologici. Ital J Neurol Sci. 1987;6:1–120.
    1. Capitani E, Laiacona M. Outer and inner tolerance limits: their usefulness for the construction of norms and the standardization of neuropsychological tests. Clin Neuropsychol. 2017;31:1219–1230.
    1. Capitani E, Laiacona M. Composite neuropsychological batteries and demographic correction: standardization based on equivalent scores, with a review of published data. J Clin Exp Neuropsychol. 1997;19:795–809.
    1. Rothstein HR, Borenstein M, Cohen J, Pollack S. Statistical power analysis for multiple regression/correlation: a computer program. Educ Psychol Measur. 1990;50:819–830.
    1. Champely S (2020) pwr: Basic functions for power analysis (R package version 1.3–0) (Computer software). The Comprehensive R Archive Network.
    1. Brugnolo A, De Carli F, Accardo J, Amore M, Bosia LE, Bruzzaniti C, Cappa SF, Cocito L, Colazzo G, Ferrara M, Ghio L. An updated Italian normative dataset for the Stroop color word test (SCWT) Neurol Sci. 2016;37:365–372.
    1. Tremolizzo L, Lizio A, Santangelo G, Diamanti S, Lunetta C, Gerardi F, Messina S, La Foresta S, Riva N, Falzone Y, Filippi M, Woolley SC, Sansone VA, Siciliano M, Ferrarese C, Appollonio I, ALS-CBS Italian Study Group ALS Cognitive Behavioral Screen (ALS-CBS): normative values for the Italian population and clinical usability. Neurol Sci. 2020;41:835–841.
    1. IBM Corp (2020) IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp
    1. R Core Team (2019) R: A Language and environment for statistical computing. (Version 3.6.3) [Computer software]. Retrieved from
    1. Aiello EN, Depaoli EG (2021) Norms and standardizations in neuropsychology via equivalent scores: software solutions and practical guides. Neurol Sci. 10.1007/s10072-021-05374-0
    1. McHugh ML. Interrater reliability: the kappa statistic. Biochemia Medica. 2012;22:276–282.
    1. Siciliano M, Raimo S, Tufano D, Basile G, Grossi D, Santangelo F, Trojano L, Santangelo G. The Addenbrooke’s Cognitive Examination Revised (ACE-R) and its sub-scores: normative values in an Italian population sample. Neurol Sci. 2016;37:385–392.
    1. Pigliautile M, Chiesi F, Stablum F, Rossetti S, Primi C, Chiloiro D, Federici S, Mecocci P. Italian version and normative data of Addenbrooke's Cognitive Examination III. Int Psychogeriatr. 2019;31:241–249.
    1. Hirnstein M, Hugdahl K, Hausmann M. Cognitive sex differences and hemispheric asymmetry: a critical review of 40 years of research. Laterality: Asymmetries of Body. Brain Cogn. 2019;24:204–252.
    1. Bush SS. Determining whether or when to adopt new versions of psychological and neuropsychological tests: ethical and professional considerations. Clin Neuropsychol. 2010;24:7–16.
    1. Mazzi MC, Iavarone A, Russo G, Musella C, Milan G, D’Anna F, Garofalo E, Chieffi S, Sannino M, Illario M, De Luca V. Mini-Mental State Examination: new normative values on subjects in Southern Italy. Aging Clin Exp Res. 2020;32:699–702.
    1. Hannay HJ, Lezak MD. The neuropsychological examination: interpretation. In: Lezak MD, Howieson DB, Loring DW, editors. Neuropsychological assessment. New York: Oxford University Press; 2004. pp. 133–155.
    1. Kolakowsky-Hayner SA, Caplan B. Qualitative Neuropsychological Assessment. In: Kreutzer JS, DeLuca J, Caplan B, editors. Encyclopedia of Clinical Neuropsychology. New York: Springer; 2011. pp. 2098–2099.
    1. Masconi KL, Matsha TE, Echouffo-Tcheugui JB, Erasmus RT, Kengne AP. Reporting and handling of missing data in predictive research for prevalent undiagnosed type 2 diabetes mellitus: a systematic review. EPMA J. 2015;6:1–11.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться