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Thats certainly fine as a composite measure over time, but the MMSE is relatively
insensitive to mild disease, says Roy Hamilton, MD, MS, an assistant professor of
neurology at the University of Pennsylvania in Philadelphia. Patients with only minor
cognitive impairment may be overlooked if this is the principal screening tool used.
Their varying degrees of sensitivity create the biggest difference and likely become the
biggest factor for determining which one is used.
For mild impairment, the MoCA is the better test, says Abhay Moghekar, MBBS, an
assistant professor of neurology at The Johns Hopkins University School of Medicine in
Baltimore. Its the more sensitive of the two and also more difficult. So if a physician has a
patient come in with minimal complaints and questions whether its affected him or her
functionally, the physician would likely choose the MoCA. If a patient comes in and is
clearly functionally impaired, theres no need for that highly sensitive test.
The MoCA discriminates very well between normal cognition and mild impairment or
dementia, but its too difficult for moderate to severe conditions, says Barbara MessingerRapport, MD, PhD, director of the Center for Geriatric Medicine at the Cleveland Clinic.
The questions are harder, though it does have some of the same testing elements as MMSE,
such as orientation to time, date, and place. And like the MMSE, MoCA also tests for recall,
but instead of having to remember three items like you would on MMSE, youre asked to
remember five.
MoCA is noteworthy for being more sensitive and therefore able to pick up on things the
MMSE might miss, adds Hamilton. It has been validated in patients who may not be
currently demented but are at the risk of progressing and getting worse.
Overall, the MMSE is likely a better test for more severe conditions, but Messinger-Rapport
says there is a ceiling and floor effect to all tests. The ceiling for MMSE is that a highly
educated person may score well on the MMSE but not be able to recognize their
grandchildren, she says.
Its also important to note that the MMSE, and to a degree the MoCA, were not designed to
be differential diagnostic tools for disambiguating between different types of cognitive
conditions, adds Hamilton. On their own, screening measures like these are poor at
determining if a patient has Alzheimers or a different degenerative disease, such as
frontotemporal dementia. More testing would be required. For instance, when a patient comes
to the Penn Memory Center, theyll get the MoCA and the MMSE, but theyll also get a much
more extensive battery of testing. Without doing a variety of tests, some issues can be
missed.
Messinger-Rapport makes an effort to reassure patients and says its common to find that
theyre nervous prior to testing. While patients may actually try to practice at home by
going through some of the test questions or try to memorize the answers, this effort will only
skew the test by providing false results and could hurt the patient in the long run.
These tests are meant to help us track a patients cognition over time and help them if theres
a need, Messinger-Rapport explains. We certainly dont want patients to be uncomfortable.
Getting an answer wrong or a low score does not mean a patient is stupid. We make sure they
realize that.
Hamilton says patients should remember they wouldnt be participating in the testing in the
first place if they or a caregiver didnt recognize there was some cause for concern. Thats
what makes it important to complete these tests so the patient can receive help if its needed.
I believe tests like this are a way to objectify and quantify something that is already a
concern and complaint, Hamilton says. These patients wouldnt be coming to the memory
center if they didnt have some sort of concern. So in a way, its that history that is the
evidence of an issue. The test is only a way to translate those concerns into an objective
language. Tests can be helpful in making a diagnosis, but it typically requires the patient or
their loved ones noticing a problem in the first place. Its only meant to help.
Lindsey Getz is a freelance writer based in Royersford, Pa