Montreal Cognitive Assessment (MoCA) Scale: Strengths, Limitations, and Implication for Clinical Practice

Pezhman  Hadinezhad; Maryam  Noroozian

doi:10.18502/ijps.v21i1.20571

Pezhman Hadinezhad Cognitive Neurology, Dementia and Neuropsychiatry Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Maryam Noroozian Cognitive Neurology, Dementia and Neuropsychiatry Research Center, Tehran University of Medical Sciences, Tehran, Iran.

DOI: https://doi.org/10.18502/ijps.v21i1.20571

Keywords: Alzheimer Disease; Dementia; Mild Cognitive Impairment; Montreal Cognitive Assessment (MoCA)

Abstract

Objective: Mild Cognitive Impairment (MCI) is a transitional state between normal aging and dementia, with high risk of progression. Early detection is essential, and so the Montreal Cognitive Assessment (MoCA) has become a widely used screening tool. Despite its popularity, concerns remain about its psychometric limitations and cultural applicability.

This review aims to critically analyze the MoCA, focusing on the validity and limitations of its subtests, and to propose directions for refinement and clinical adaptation.

Method: We conducted a structured narrative review (2005–2024) using PubMed, Scopus, and Web of Science databases. Search terms included “Montreal Cognitive Assessment”, “MoCA”, “validity”, “psychometrics”, and “cultural adaptation”. Studies evaluating psychometric performance, cultural adaptations, and clinical applications of the MoCA were included. Case reports and studies lacking psychometric evaluation were excluded. An item-by-item critical appraisal was performed.

Results: The MoCA shows superior sensitivity for MCI detection compared to the Mini-Mental State Examination (MMSE), with strengths in brevity, multidomain coverage, and accessibility. However, limitations include: superficial executive function (EF) assessment, cultural and educational bias, lack of recognition/cueing in memory testing, simplistic binary scoring, and risk of floor/ceiling effects. These may affect diagnostic accuracy across populations.

Conclusion: The MoCA remains a valuable tool but should not be used in isolation. Clinicians must consider the cultural/educational context when interpreting results. Refinements such as weighted scoring, cued recall, and culturally adapted items, alongside digital versions, could improve accuracy and fairness. Further empirical validation of these modifications is needed.