The Montreal Cognitive Assessment—Basic: A Screening Tool for Mild Cognitive Impairment in Illiterate and Low-educated Elderly Adults

Parunyou Julayanont, MD; Sookjaroen Tangwongchai, MD; Solaphat Hemrungrojn, MD; Chawit Tunvirachaisakul, MD; Kammant Phanthumchinda, MD; Juntanee Hongsawat, BSN; Panida Suwichanarakul, BSN; Saowaluck Thanasirorat, BSN, Med; Ziad S. Nasreddine, MD


J Am Geriatr Soc. 2015;63(12):2550-2554. 

In This Article

Abstract and Introduction


Objectives: To assess the validity of a newly developed cognitive screening tool, the Montreal Cognitive Assessment—Basic (MoCA-B), in screening for mild cognitive impairment (MCI) in elderly adults with low education and varying literacy.

Design: Cross-sectional.

Setting: Community hospital in Bangkok, Thailand.

Participants: Cognitively normal controls (n = 43) and individuals with MCI according to the National Institute on Aging-Alzheimer's Association work group criteria (n = 42) aged 55 to 80 with less than 5 years of education.

Measurements: MoCA-B scores.

Results: Mean MoCA-B scores were 26.3 ± 1.6 for illiterate controls and 21.3 ± 3.8 for illiterate participants with MCI (P < .001) and 26.6 ± 2.0 for literate controls and 23.0 ± 2.1 for literate participants with MCI (P < .001). MoCA-B scores did not differ significantly according to literacy, and multiple regression suggested no association with age or education. The optimal cutoff score of 24 out of 25 yielded 81% sensitivity and 86% specificity for MCI (area under the receiver operating characteristic curve = 0.90, P < .001). Test–retest reliability was 0.91 (P < .001), and internal consistency was 0.82. Administration time was 15 to 21 minutes.

Conclusion: The MoCA-B appears to have excellent validity and addresses an unmet need by accurately screening for MCI in poorly educated older adults regardless of literacy.


Mild cognitive impairment (MCI) is conceptualized as a transitional stage between normal aging and dementia. Detecting MCI is important because it allows affected individuals to receive additional support, early intervention, and close monitoring. To facilitate the detection of MCI, many health professionals around the world are using the Montreal Cognitive Assessment (MoCA) because it has been well accepted as a sensitive and efficient screening tool.[1]

The MoCA was originally validated in a sample of individuals with a high level of approximately 13 years of formal education.[2] Several MoCA subtests incorporate tasks that formal education or literacy levels may influence, and as a result, bias may be introduced when illiterate older adults or those with low levels of education effectively underperform. Similar educational biases have been observed, such as with the Mini-Mental State Examination (MMSE), a widely used measure of global cognitive function.[3] Because education and literacy may influence cognitive test performance, dissociating cognitive impairment from normal aging remains challenging when screening for MCI in these groups.

Accurate and well-designed screening measures are needed to support the detection of MCI in illiterate and low-educated individuals. This is an important problem because approximately 16% of the global population, or 773 million adults, were estimated to be illiterate according to a large United Nations Educational, Scientific and Cultural Organization survey in 2011.[4] The MoCA—Basic (MoCA-B) was therefore developed to facilitate the detection of MCI in illiterate and low-educated individuals. The present study aimed to establish the validity of the MoCA-B in Thai older adults with limited education and varying literacy levels.