Underestimation of Cognitive Impairment by Mini-Mental State Examination Versus the Montreal Cognitive Assessment in Patients With Transient Ischemic Attack and Stroke A Population-Based Study

Background and Purpose-The Mini-Mental State Examination (MMSE) is insensitive to mild cognitive impairment and executive function. The more recently developed Montreal Cognitive Assessment (MoCA), an alternative, brief 30-point global cognitive screen, might pick up more cognitive abnormalities in patients with cerebrovascular disease. Methods-In a population-based study (Oxford Vascular Study) of transient ischemic attack and stroke, the MMSE and MoCA were administered to consecutive patients at 6-month or 5-year follow-up. Accepted cutoffs of MMSE <27 and MoCA <26 were taken to indicate cognitive impairment. Results-Of 493 patients, 413 (84%) were testable. Untestable patients were older (75.5 versus 69.9 years, P < 0.001) and often had dysphasia (24%) or dementia (15%). Although MMSE and MoCA scores were highly correlated (r(2) = 0.80, P < 0.001), MMSE scores were skewed toward higher values, whereas MoCA scores were normally distributed: median and interquartile range 28 (26 to 29) and 23 (20 to 26), respectively. Two hundred ninety-one of 413 (70%) patients had MoCA <26 of whom 162 had MMSE >= 27, whereas only 5 patients had MoCA >= 26 and MMSE <27 (P < 0.0001). In patients with MMSE >= 27, MoCA <26 was associated with higher Rankin scores (P = 0.0003) and deficits in delayed recall, abstraction, visuospatial/executive function, and sustained attention. Conclusion-The MoCA picked up substantially more cognitive abnormalities after transient ischemic attack and stroke than the MMSE, demonstrating deficits in executive function, attention, and delayed recall. (Stroke. 2010; 41:1290-1293.)