Montreal Cognitive Assessment in Assessing Clinical ...

1 64 Acta Neurologica Taiwanica Vol 21 No 2 June 2012 From the Departments of 1 Neurology, 2 Radiology, KaohsiungChang Gung Memorial Hospital and Chang Gung UniversityCollege of Medicine, Kaohsiung, December 15, 2011. Revised March 7, March, to: Nai-Ching Chen, MD. Department ofNeurology, Kaohsiung Chang Gung Memorial Hospital, , Ta-Pei Road, Niaosung, Kaohsiung County 833, : Cognitive Assessment in Assessing Clinical Severity and White Matter Hyperintensity in Alzheimer s Disease with Normal Control ComparisonYa-Ting Chang1, Chiung-Chih Chang1, Hung-Sheng Lin1, Chi-Wei Huang1, Wen-Neng Chang1,Chun-Chung Lui2, Chen-Chang Lee2, Yu-Ting Lin1, Chang-Hung Chen1, Nai-Ching Chen1 Abstract-Purpose: Use Taiwanese version of the Montreal Cognitive Assessment (MoCA) in evaluating patients indifferent stages of Alzheimer s disease (AD) and correlate with white matter change.

2 Methods:Ninety-seven normal controls (NC), 52 very-mild AD ( Clinical dementia rating [CDR] = ), 48mild AD (CDR = 1) and 38 moderate AD (CDR = 2) patients were enrolled for the MoCA, Mini-Mental State Examination (MMSE) and the Cognitive Assessment Screening Instrument (CASI). Whitematter hyperintensities (WMHs) on brain MRI were visually rated and classified as deep or periventric-ular :In NC group, education ( = , p < ) but not age ( = , p = ), was significantlyrelated to MoCA score. However, while we added two points to the AD patients with less than 6 yearseducation, the effects of education disappeared as compared with those of 7 years of education.

3 For alleducational levels, the cutoff value of MoCA for very-mild AD was 22/23 (sensitivity = , speci-ficity = ). No significant differences were found in the areas under the curves that differentiatedNC from the patients with AD for MoCA and MMSE (differences = , p = ), or for MoCAand CASI (differences = , p = ). Total WMHs, frontal deep and periventricular WMHs wereinversely correlated with the attention and delayed-recall :The MoCA is a good Clinical tool for screening very-mild stage AD if the educational effectsare carefully considered. The correlation between the executive subdomains with the frontal WMHsalso makes it a useful tool for detecting subtle words: Montreal Cognitive Assessment , Alzheimer s disease, white matter hyperintensities, CognitiveAbility Screening Instrument, Mini-Mental State ExaminationActa Neurol Taiwan 2012;21:64-7321:1-65 Acta Neurologica Taiwanica Vol 21 No 2 June 2012 INTRODUCTIONThe Montreal Cognitive Assessment (MoCA) is acognitive battery for screening patients with early cogni-tive impairment which was validated in 2005(1).

4 TheMoCA is a rapid and sensitive tool for detecting mildcognitive impairment(1,2). In contrast with the Mini-Mental State Examination (MMSE)(3), MoCA scores areadjusted to compensate for educational differencesbetween subjects. In the initial study, the cutoff valuebetween normal controls (NC) and mild cognitiveimpairment was 25/26(1). Several additional studies explored the utility of theMoCA for evaluating Cognitive performance in patientswith subcortical dementia arising from Parkinson s dis-ease(4), Huntington s disease(5)and small vessel diseases(6). The MoCA was more sensitive than the MMSE fordetecting early Cognitive deficits in patients withParkinson s disease(7).

5 In addition, the MoCA was betterthan the MMSE for capturing memory, language, execu-tive, and visuospatial deficits in Huntington s disease(5)with anatomical pathologies in the caudate nuclei andconnected cortical regions. Furthermore, the functionalcapacity scale scores were also correlated more highlywith MoCA scores than with MMSE scores(5). Using anoptimal cutoff of 21/22, the MoCA has been shown tohelp differentiate between controls and patients withsmall vessel diseases and lacunas and white matter dam-age(6). Although pathological studies suggest that whitematter hyperintensities (WMHs) may be ischemic in ori-gin and are caused by consistent or variable hypoperfu-sion, there is emerging evidence that they may alsoreflect the vascular deposition of beta-amyloid, particu-larly when they are distributed in the posterior brainregions in patients with Alzheimer s disease (AD)(8).

6 Patients with AD manipulate information at a slowerspeed, implying the coexistence of subcortical dysregu-lation(9). In recent studies focusing on AD patients, wedetermined that WMHs should not be dismissed as inci-dental findings, because there is a close inter-relation-ship with vascular risk factors(10)and poor Cognitive per-formance(11). Based on a literature review that usage of the MoCAis a sensitive screening battery for cortical and subcorti-cal dementia(5-7), the aim of this study was to investigatewhether that also applies to different staging of AD withvariable WMHs. The optimal cutoff points for theMoCA in very-mild AD were determined and comparedwith the MMSE and Cognitive Assessment screen instru-ment (CASI) for their screening ability.

7 The executiveand non-executive subdomains derived from the MoCAwere also calculated and correlated with the visuallyrated WMH AND METHODSS ubjectsThe Department of Neurology at Kaohsiung ChangGung Memorial Hospital recruited 97 NC and 138 ADpatients for this study. The Clinical diagnosis of AD wasbased on the National Institute of Neurological andCommunicative Disorder and Stroke-Alzheimer sDisease and Related Disorders Association (NINCDS-ADRDA), and the Diagnostic and Statistical Manual ofMental disorders, 4th edition (American PsychiatricAssociation, 1994)(12). Each AD patient underwent anextensive medical examination during the initial visit,including a standard medical history, physical and neuro-logic examination, and a brain magnetic resonance imag-ing (MRI) scan.

8 We defined patients with a clinicaldementia rating (CDR)(13)score of as very-mild AD,1 as mild AD, and 2 as moderate AD. The exclusion criteria included: (1) history of clini-cal stroke, (2) modified Hachinski ischemic score > 4; (14)(3) abnormal liver function test results (reference: aspar-tate aminotransferases < 40 and alanine aminotransferase< 56); and (4) low vitamin B12 levels (reference: 185pg/ml). The NC were come from our normative databaseduring routine examinations. None of the NC had a his-tory of neuropsychological disorders, and all had normalcomplete blood counts, electrolyte panels, renal functiontests and liver function tests.

9 The CASI scores for all NCwere within the reference limit for Taiwan,(15)and all ofthe NC had a CDR score of zero. The Human Ethics66 Acta Neurologica Taiwanica Vol 21 No 2 June 2012 Committee of Chang Gung Memorial Hospital approvedthis Taiwan version The MoCA Taiwan version was downloaded fromthe website ( ) and administeredaccording to the instructions of Nasreddine et al(1). TheMoCA assesses 7 subdomains: visuospatial/execution,naming, attention, language, abstraction, delayed-recalland orientation. The executive subdomains include visu-ospatial-execution, abstraction, attention and orientation,while the remaining 3 were categorized as non-executivesubdomain in this study.

10 One point was added for thesubjects who had received 12 years or less of MoCA Taiwan version differs from the English ver-sion in the following: (1) In the visuospatial test, Englishalphabet letters are substituted with , , , and ,which are common serial words in Chinese. (2) In theattention test, English alphabet letters are substitutedwith numbers. (3) In the language test, the patients wereinstructed to generate the word within the semantic cate-gory of fruit instead of the phonemic category in theEnglish version . Two additional batteries were adminis-tered at the same visit for comparison with the followingorders: MMSE(2), MoCA and CASI(16).