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 »  Abstract
 » Introduction
 »  Materials and Me...
 » Results
 » Discussion
 » Acknowledgment
 »  References
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Table of Contents    
Year : 2015  |  Volume : 63  |  Issue : 1  |  Page : 63-67

Validity of Montreal Cognitive Assessment in Non-English speaking patients with Parkinson's disease

1 Comprehensive Care Center for Movement Disorders, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
2 Department of Neurology, Cognition and Behavioral Neurology Section, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
3 Achutha Menon Centre for Health Science Studies (AMCHSS), Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Web Publication4-Mar-2015

Correspondence Address:
Dr. Syam Krishnan
Associate Professor of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram - 695 011, Kerala
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Source of Support: Project Number: 5247 of the Comprehensive Care Centre for Movement Disorders, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India, Conflict of Interest: None

DOI: 10.4103/0028-3886.152637

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 » Abstract 

Background: The Montreal Cognitive Assessment is a brief and easy screening tool for accurately testing cognitive dysfunction in Parkinson's disease. We tested its validity for use in non-English (Malayalam) speaking patients with Parkinson's disease.
Materials and Methods: We developed a Malayalam (a south-Indian language) version of Montreal Cognitive Assessment and applied to 70 patients with Parkinson's disease and 60 age- and education-matched healthy controls. Metric properties were assessed, and the scores were compared with the performance in validated Malayalam versions of Mini Mental Status Examination and Addenbrooke's Cognitive Examination.
Results: The Montreal Cognitive Assessment-Malayalam showed good internal consistency and test-retest reliability and its scores correlated with Mini Mental Status Examination (patients: R = 0.70; P < 0.001; healthy controls: R = 0.26; P = 0.04) and Addenbrooke's Cognitive Examination (patients: R = 0.8; P < 0.001; healthy controls: R = 0.52; P < 0.001) scores.
Conclusion: This study establishes the reliability of cross-cultural adaptation of Montreal Cognitive Assessment for assessing cognition in Malayalam-speaking Parkinson's disease patients for early screening and potential future interventions for cognitive dysfunction.

Keywords: Cross-cultural adaptation; Malayalam; Montreal Cognitive Assessment; Parkinson′s disease; validation

How to cite this article:
Krishnan S, Justus S, Meluveettil R, Menon RN, Sarma SP, Kishore A. Validity of Montreal Cognitive Assessment in Non-English speaking patients with Parkinson's disease. Neurol India 2015;63:63-7

How to cite this URL:
Krishnan S, Justus S, Meluveettil R, Menon RN, Sarma SP, Kishore A. Validity of Montreal Cognitive Assessment in Non-English speaking patients with Parkinson's disease. Neurol India [serial online] 2015 [cited 2021 Oct 24];63:63-7. Available from:

 » Introduction Top

Non-motor manifestations contribute significantly to the morbidity resulting from Parkinson's disease (PD). [1],[2] Cognitive dysfunction is one of the important non-motor symptoms of PD. [3],[4] Cognitive dysfunction in PD ranges from mild cognitive impairment (PD-MCI) to PD dementia (PDD) and increases the risk of nursing home placement, contributes to a more malignant course of illness, and exacerbates personal and socioeconomic burden. [5],[6] PD-MCI is common and appears to place patients at risk of progressing to dementia; [7] even mild cognitive deficits in PD are associated with functional impairment [8],[9] and poor quality of life (QOL). [10],[11]

The Montreal Cognitive Assessment (MoCA) was designed by Nasreddine and colleagues [12] as a screening tool for MCI and has become an increasingly popular screening tool, because it is a brief and easily administered even by non-specialist staff members and addresses frontal functions better than the widely used Mini-Mental Status Examination (MMSE). [13] It is a single-page, 30-point test addressing the following functions: Short-term memory (delayed recall - 5 points), visuospatial function (copying a cube and clock-drawing - 4 points), executive function (phonemic fluency, abstraction, and modified trail making-B task - 4 points), attention, concentration, and working memory (target detection using tapping, serial subtraction, digits forward and backward - 6 points), language (naming, sentence repetition - 5 points), and orientation (6 points). The administration of the test takes only around 10 minutes; the suggested cut-off is 26. MoCA has been translated and is available ( in more than 40 languages other than English. [14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] Its validity as a screening tool for cognitive dysfunction and its superiority over MMSE have been demonstrated, not only in MCI but also in the setting of Alzheimer disease, stroke, vascular dementia, traumatic brain injury, and frontotemporal dementia. [26],[27],[28],[29],[30],[31] The usefulness of MoCA as a suitable, accurate, and brief test for screening all levels of cognition in PD has also been established. [32],[33] The present study aimed to test the metric properties and reliability of a cross-cultural adaptation of MoCA for use in Malayalam-speaking patients with PD.

 » Materials and Methods Top

MoCA is copyright protected, and permission was obtained for translation and used for the present study. The English version was used as a base for translation into Malayalam, the regional language spoken by 35 million residents of the state of Kerala, South India. The 5-word recall and sentence repetition items were adapted to the language and culture. In order to ensure accurate translation of the test and instructions, back translation (from Malayalam to English) was done and compared with the original English version. The translation and back-translation were done independently by two bilingual experts, who are clinical psychologists and well-versed with similar tasks, and consensus was obtained. The final version was discussed and approved within the internal committee consisting of the bilingual experts as well as the investigators.

The Malayalam version of MoCA (MoCA-M) was applied to consecutive patients with PD, attending the Movement Disorders clinic of our hospital, as well as age- and education-matched healthy controls. All the patients were diagnosed using the United Kingdom Parkinson's Disease Society Brain Bank Diagnostic Criteria [34] and had at least 10 years of formal education and were able to read, understand, and write Malayalam well. The controls did not have any neurological symptoms and were normal on neurologic examination (except for assessment of higher mental functions). Those with clinically significant depression (Beck's Depression Inventory) [35] or any significant neurological, psychiatric, or medical co-morbidity affecting cognitive functions or interfering with cognitive testing in the judgment of the investigators, were excluded.

The age of onset of motor symptoms of PD, duration of motor symptoms and details of ongoing treatment were collected by directly interviewing the patients/caregivers and by review of hospital files. The severity of motor symptoms of PD was assessed by the Hoehn and Yahr stage. All the subjects (PD patients and controls) underwent neuropsychological assessment using MoCA-M, MMSE, and Addenbrooke's Cognitive Examination (ACE). [36],[37] The neuropsychologic evaluation was done in the "on" state, for all PD patients with motor fluctuations. A subgroup of subjects was re-examined using the MoCA-M after an interval of 2 weeks to determine the test-retest reliability. The study protocol was approved by the Institutional Ethics Committee, and all study participants gave written informed consent form.

Cronbach's alpha was calculated to assess the internal consistency of MoCA-M. Spearman's correlation co-efficient was used to the assess test-retest reliability as well as to assess the relationship between MoCA-M scores and the performance in other cognitive tests. The data were analyzed using statistics software (Statistical Package for the Social Sciences (SPSS) Inc, Illinois, Chicago).

 » Results Top

There were 70 patients with PD and 60 healthy controls. Among the patients, 21 were women. The mean age of the patients was 57.9 (±9.1) years; the mean duration of motor symptoms was 7.1 (±4.2) years. The severity of motor symptoms was as follows: Hoehn and Yahr (H and Y) stage 1−5 (7.1%), stage 2−18 (25.7%), stage 2.5−15 (21.4%), stage 3−27 (38.6%), and stage 4−5 (7.1%). There was no significant difference between patients and controls about age (57.9 ± 9.1 vs. 58.3 ± 7.7; P = 0.2) or number of years of education (12.5 ± 3.0 vs. 12.1 ± 3.6; P = 0.12).

MoCA-M showed good internal consistency; the Cronbach's alpha for MoCA-M was 0.76 in patients with PD. There was also excellent test-retest reliability for the total score of MoCA-M, as well as for the individual items [Table 1]. The mean MoCA-M, MMSE, and ACE scores of the patients and healthy controls are shown in [Table 2]. The MoCA-M scores correlated well with the MMSE (R = 0.70; P < 0.0001) and ACE (R = 0.81; P < 0.0001) scores in patients with PD. The healthy controls showed good correlation of MoCA scores with ACE (R = 0.52; P < 0.0001); however, correlation with MMSE scores (R = 0.26; P = 0.04) was weak. The scores in all the three tests differed significantly between patients and normal controls [Table 2].
Table 1: Test-retest reliability of MoCA-M

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Table 2: The MoCA-M, MMSE, and ACE scores of patients and healthy controls

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 » Discussion Top

Cognitive dysfunction is a common non-motor manifestation of PD with high clinical relevance; its identification in early stages is important for research as well as standard patient care. [7] The motor dysfunction and reduced endurance in patients with PD demand for screening tests, which are brief and easy to administer; they also need to be sensitive for the type of cognitive dysfunction expected in PD. MoCA is well-recognized as a suitable test for cognition in PD [32],[33] and has been translated to many languages.

In this pilot study, we demonstrate the usefulness of the Malayalam version of MoCA for screening cognitive functions in PD. MoCA-M (the test and instructions for testing are available on line at was created by translating MoCA to Malayalam and cross-culturally adapting the relevant items. MoCA-M showed good internal consistency, and the test-retest reliability was excellent. For comparison, we selected ACE for several reasons-it is a brief test battery encompassing all the cognitive domains, [36] its validity in PD has been demonstrated, [38] its validated adaptation for Malayalam speaking population is available, [37] and it gives the MMSE score also. We found that MoCA-M scores of patients correlated well with their performance in ACE. The MoCA-M scores also showed good correlation with MMSE scores in patients with PD. MoCA-M is more brief and easy to administer compared to ACE; MoCA's superiority for testing cognition in PD, compared to MMSE has already been demonstrated. [39] The cognitive dysfunction in PD is characterized by a frontal, attentional-executive dysfunction in most patients, in addition to visuospatial defects and memory problems. [40],[41],[42],[43] The utility of MoCA for screening cognition in PD and its superiority over MMSE are not surprising as it tests frontal functions better than MMSE, in addition to testing the other cognitive domains.

We also examined 60 age- and education-matched healthy volunteers and demonstrated good correlation of MoCA-M scores with performance in ACE. However, unlike the observation in patients with PD, correlation with MMSE scores was weak. The MMSE scores were significantly higher for healthy volunteers, and the poor correlation between MoCA-M and MMSE scores in this group is attributable to the ceiling effect of MMSE, [39],[44] which is not observed for MoCA.

We found that the performance of patients with PD in all the three tests was significantly worse compared to controls. The mean duration of motor symptoms of PD in our patient group was 7.1 years, and nearly two-thirds of the patients were H and Y stage 2.5 or above. It has been shown that the burden of cognitive dysfunction increases with the duration and severity of PD. [7],[45],[46] This explains the significant difference in the performance between patients and the control population; this also could account for the patient group's mean MoCA score falling below the cut-off levels defined for MCI, for the original version of MoCA. [33] However, as MoCA-M is a cross-cultural adaptation of MoCA, its cut-off scores need to be separately defined. The aim of the present study was primarily a cross-cultural adaptation of MoCA for use in Malayalam speaking patients with PD, assessment of its metric properties and comparison with other established tests available in Malayalam. We have initiated the second phase of our study, in which we plan to collect normative data for MoCA-M based on age and level of education and test patients with PD using MoCA-M as well as a more elaborate test battery needed for a level II diagnosis of PD-MCI [47] as per recent recommendations. We hope to confirm the cut-off levels for MOCA-M in this study.

We found that MoCA-M is easy to administer, and took only around 10 minutes, on an average, in our non-English speaking patients with PD. The good correlation with ACE, which is a more elaborate test battery and well-validated in patients with PD, [38] points to its utility as a brief and easy instrument for screening for PD-MCI and PD-D.

 » Acknowledgment Top

We sincerely thank Dr. Nasreddine ZS for permitting us to translate and use MoCA for our research. We also thank Mr. Gangadhara Sarma, Clinical Psychologist, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (for the assistance in translation) and all patients and healthy volunteers who participated in the study.

 » References Top

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