Modified MoCA for Infection Control Precautions

Vol 7 #4

James A. Bourgeois, O.D., M.D.

Chair, Department of Psychiatry, Baylor Scott & White Health, Central Texas Division

Clinical Professor (Affiliated), College of Medicine,

Texas A&M University Health Science Center

2401 South 31st Street, Temple TX 76508 USA

Telephone: 254-724-4071/Fax: 254-724-1747/Email: [email protected]

To the Editor

The coronavirus pandemic raises extra concerns about infection control precautions and interpersonal transmission of infectious diseases. Yet, the need for full assessment of psychiatry consultation patients remains important, if not accentuated, during times of serious systemic illness in the hospital population.  A popular, easy to administer, and validated cognitive assessment is the Montreal Cognitive Assessment (“MoCA”) (1). The test, instructions for use, one-hour course in administration, supportive references, and multiple versions in many languages are available at www.mocatest.org. The test consists of standardized tests of various cognitive domains and has a maximum score of 30; a score of 26 or more is considered to be in the normal range.

Our consultation-liaison team routinely administers this examination as part of our initial assessments, as we find it very valuable in assessment of delirium, major neurocognitive disorder, and other psychiatric illnesses.  However, the top three items on the testing form (trails B, copy of geometrical shape, and clock drawing) require the patient to handle a pen and to touch the test paper.  This portion of the test is already problematic for patients with motor deficits and visual impairment, but concerns of infection control make potentially infected patients’ handling of the pen and test paper problematic. However, the imperative for cognitive assessment remains, so completely eliminating the test is not desirable.

In light of this concern, when infection control concerns are paramount, our team omits these items and completes the other 25 points (which are accomplished verbally). While there admittedly is thus some sacrifice of data pertinent to visual-spatial function, the preservation of the bulk of the test provides important (if somewhat incomplete) clinical information helpful for diagnosis.

Since we are eliminating some content from the “MoCA”, our team informally refers to the modified test as a “modified MoCA” or (colloquially and humorously, using coffee shop parlance) the “Latte.” We have not been in a position to study the psychometric properties of this modified examination, but find that this modification enhances infection control while preserving the majority of the utility of this examination. We score the modified test as “modified MoCA” with a denominator of 25, not 30.  A modification of the MoCA by eliminating the visual elements (the five points discussed above, plus naming of three animal pictures) for telephonic administration (yielding 22 net points, with a cutoff of >/= 19) is recommended by the test developers (2).

Given current concerns for infection control, psychiatry needs to play a part, while continuing to provide comprehensive patient care. Study of the slightly modified examination in the diagnosis of cognitive disorders would be valuable regarding its psychometric properties.

References

1. Nasreddine, Z. (2010). Montreal Cognitive Assessment (MoCA) Administration and Scoring Instructions. Montreal Cognitive Assessment website. http://www.mocatest.org/wp-content/uploads/2015/tests-instructions/MoCA-Instructions-English_2010.pdf. Updated August 18, 2010. Accessed March 27, 2020.
2. https://mailchi.mp/mocatest/remote-moca-testing?e=014a235cfb