Neuroscience & Medicine, 2010, 1, 39-42
doi:10.4236/nm.2010.12006 Published Online December 2010 (http://www.SciRP.org/journal/nm)
39
Comparison of the Folstein Mini Mental State
Examination (MMSE) to the Montreal Cognitive
Assessment (MoCA) as a Cognitive Screening Tool
in an Inpatient Rehabilitation Setting
Arun Aggarwal1, Emma Kean2
1Clinical Associate Professor, Department of Rehabilitation Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia;
2Senior Occupational Therapist, Balmain Hospital, Balmain, NSW, Australia
Received August 19th, 2010; revised September 14th, 2010; accepted September 28th, 2010
ABSTRACT
Identifying the presen ce of cognitive impairment in patients admitted for inpatient rehabilita tion is important as it may
impact on their ability to particip ate in a rehab ilitation program. The Folstein Min i Mental State Examina tion (MMSE)
has been used by clinicians as a cognitive screening tool for its convenience, even though it is not sensitive, and often
fails to detect cognitive impairment. Recently, the Montreal Cognitive Assessment (MoCA) has been developed as a
brief cognitive screening tool to detect mild-moderate cognitive impairment. We performed a longitudinal study to
compare the utility of the MMSE and MoCA in an inpatient rehabilitation setting. A total of 50 consecutive patients
were studied with an average age of 71.7 years of age. The mean test score for MMSE was 26.5 and 22.2 for the MoCA.
The Pearson’s correlation coefficient between the scores was 0.695 (p < 0.003). The mean performance time for the
MMSE was 7.4 minutes and 14.8 minutes for the MoCA. MMSE did not perform well as a screening instrument for mild
cognitive impairment as there were 43 patients who scored 24 or more on MMSE, and 25 patients (58%) scored 25 or
less on MoCA, indicating the presence of cognitive impairment. Even though the MoCA takes longer to administer, the
additional important information provided indicates that the MoCA should be used rather than the MMSE as a cogni-
tive screening tool.
Keywords: MMSE, MoCA, Rehabilitatio n
1. Introduction
Mild cognitive i mpairment is common in elderly patien ts
and can impact on prognosis and quality of life [1]. The
areas of cognitive impairment that occur at this stage
primarily involve attention, verbal fluency, executive
function and visuo-spatial skills, which differs from the
language and memory skills that are commonly associ-
ated with dementia [2]. Identification of mild cognitive
impairment in patients admitted for inpatient rehabilita-
tion is important as th is may an impact on their ability to
participate actively in a multi-disciplinary rehabilitation
program and achieve their rehabilitation goals.
Cognitive screening tools in the elderly are important
for the purpose of identifying the presence of cognitive
impairment. Neuropsychological testing is the gold-stan-
dard for assessing dementia and cognitive impairment,
but it is time-consuming and requires highly trained as-
sessors [3]. The most commonly used cognitive screening
tool, the Folstein Mini Men tal State Ex amination (MMSE)
[4], is convenient, but not sen sitive, as it is influenced by
age, socio-economic status and level of education. It as-
sesses primarily language and memory skills and has
been found to be insensitive to detecting mild cognitive
impairment [5]. Riedel in a large study of 873 Parkinsons
disease patients found the MMSE had a sensitivity of
only 50% when compared to DSM-IV criteria for demen-
tia [6]. Therefore, there is a need for a brief, accurate and
easily performed screening test.
The Montreal Cognitive Assessment (MoCA) [7], has
been developed as a brief cognitive screening tool to de-

Comparison of the Folstein Mini Mental State Examination (MMSE) to the Montreal Cognitive Assessment
(MoCA) as a Cognitive Screening Tool in an Inpatient Rehabilitation Setting
40
tect mild-moderate cognitive impairment. It has been
found to have high sensitivity and specificity for the de-
tection of mild cognitive impairment. A score of less than
25 was found to be the optimal cut-off point for a diag-
nosis for mild cogn itive impairment.
Hoops and Gill compared the MMSE and MoCA to
neuropsychological battery (n = 132 and n = 38 respec-
tively), both finding greater ability to detect cognitive
impairment using the MoCA. Gill also found good test-
retest reliability (0.79), inter-rater reliability (0.81) and co r-
relation when compared to a neuropsychological battery
[8,9].
This study compares the utility of the MMSE and
MoCA in an inpatient rehabilitation setting for everyday
clinical use. The aim was to determine the correlation be-
tween the MMSE and MoCA scores in individual patients
to determine whether the MoCA could be used as a cogni-
tive screening tool to detect mild cognitive impairment.
2. Method
Patients transferred to a general sub-acute rehabilitation
ward of the Sydney South West Area Health Service be-
tween a 6 month period where consecutively recruited
into the study. A policy was already in place that patients
over the age of 65 had a MMSE performed as part of their
conventional rehabilitation assessment. Written consent was
obtained to also perform the MoCA assessment on all
patients. All assessments were conducted by qualified
occupational therapists working on the rehabilitation
ward.
Assessment were conducted at least 3 days after being
admitted to the ward, so that patients had time to settle into
the new ward environment. Patients were examined in an
ambient clinical setting. The same therapist performed the
MMSE assessment first, followed by the MoCA, on all
patients. The time between each test was at least 30 min-
utes. A modified MMSE using “WORLD” backwards was
used for attention testing. Patients who were medically
unstable (delirium), had an aphasia, refused or were from a
non-English speaking background were excluded from the
study. The study was performed with approval obtained
though the Human Resources and Ethics Committee of
Sydney South West Area Health Service.
Demographic information was collected including eth-
nicity, language spoken at home, years of education, prior
history of dementia, principle diagnosis and diagnosis.
The MMSE and MoCA scores were obtained as well as
the time taken to perform each test.
All statistical procedures were performed with SPSS
10.0 for Windows. The correlation between MMSE and
MoCA results was measured using the Pearson Product
Moment Correlation. The Perarson’s coefficient reflects
No. of Cases
5044383125191371
MM SE / Mo CA sco re
30
20
10
0
MMS E
MOC A
Figure 1. Graph showing comparison of MMSE and MoCA
scores.
the degree of linear relationship between the two vari-
ables. T-tests were performed on the difference between
two dependent samples of results of MMSE and MoCA
and time taken to perform these tests.
3. Results
A total of 50 patients were studied. The average age of
subjects was 71.7 years of age, ranging from 31 to 98
years of age. There were 31 males and 19 females. The
mean period of education was 11.7 years with 78% of
subjects completing at least up to Year 10 at school. 67%
of patients completed 12 or more years of education.
The majority primary diagnoses were neurological 42%,
(stroke, falls), deconditioned post-operatively 38% (ab-
dominal and cardiac surgery) and orthopaedic 20% (total
hip and knee replacements). 92% of subjects spoke Eng-
lish as their primary language at home. The other 4 (8%)
spoke another language at home, but had no problems
with performing the MMSE and MoCA assessments in
English. There was only 1 patient who reported having a
previous history of dementia.
MMSE scores ranged from 16 to 30 with a mean MMSE
test score of 26.5 with a standard deviation of 3.5. The mean
MoCA scores ranged from 11 to 30 with a mean MoCA test
score of 22.2 with a standard deviation of 5.1.
The Pearson’s correlation coefficient between MMSE
and MoCA score was poor at 0.695. A graph showing the
comparison between the MMSE and MoCA scores is
shown in Figure 1. The difference between MMSE and
MoCA scores ranged from 0 to 14, with a mean differ-
ence of 4.6.
The performance time for the MMSE ranged from 4 to
12 minutes with a mean time of 7.4 minutes with a stan-
dard deviation of 2.3 minutes. The performance time for
MoCA ranged from 5 to 30 minutes with a mean per-

Comparison of the Folstein Mini Mental State Examination (MMSE) to the Montreal Cognitive Assessment
(MoCA) as a Cognitive Screening Tool in an Inpatient Rehabilitation Setting
41
No. of Cases
5044383125191371
Time (mins)
30
20
10
0
TIMEMMSE
TIMEMO C A
Figure 2. Graph showing comparison between time taken to
perform MMSE and MoCA.
formance time of 14.8 minutes with a standard deviation
of 4.7 minutes.
Th e Pearson’s corr elation coeff icient betw een time t a ke n
to perform MMSE and MoCA was also poor at 0.672. A
graph show ing the comparison be tween the time taken to
perform MMSE and MoCA is shown in Figure 2.
4. Discussion
This is a study using MoCA in an inpatient reh abilitation
setting and comparing the utility of the MMSE and
MoCA in an inpatient rehabilitation setting for everyday
clinical use. We found that the MMSE does not perform
well as a screening instrument for mild cognitive im-
pairment due in part to the lack of sensitivity to milder
cogniti v e de fi ci ts wi t h 10 p at ie nt s (2 0% ) ac hie vi ng a perfect
score on MMSE compared to only 3 patients (6%) on
MoCA. In addition, of the 43 patients with intact global
cognition, with a “normal” score on the MMSE, defined
as greater than or equal to a score of 24, 25 patients (58%)
scored 25 or less on MoCA, indicating the presence of
cognitive impairment.
Cognitive assessments of inpatients are critical as it in-
fluences both long and short term management. Mild
cognitive impairment is an intermediate clinical state
between normal cognitive aging and dementia, which
proceeds and leads to dementia in many cases. The con-
cept of mild cognitive impairment is evolving and some-
what controversial although several screening instru-
ments are available for detecting dementia, the MMSE is
the most widely used by clinicians and remains the stan-
dard cognitive screening tool in every day clinical prac-
tice in many Australian institutions.
However, MMSE is influenced by age, gender, level of
education, and socio-economic status. It assesses primar-
ily language and memory skills and has been found to be
insensitive to mild cognitive impairment. To address this
problem, the MoCA was develop ed as a cognitive tool to
screen patients who present with mild cognitive impair-
ment and usually perform in the normal range for MMSE.
The data indicates excellent test-retest reliability and posi-
tive and negative predictive values for mild cognitive
impairment.
Cognitive assessment of inpatients is more challenging
than community patients, as intercurrent physical ill-
nesses, deconditioning, increased anxiety, mental illness
and noise and distractions, all affect performance. This
study however shows that the MoCA is much more sen-
sitive than the MMSE, and even though it is slightly more
time consuming, the additional information it provides
makes it a more useful clinical cognitive tool that the
MMSE.
Even though the MoCA took nearly twice as longer to
perform, therapists preferred the MoCA, despite their
initial lack of familiarity with the assessment. Clinicians
commented the MoCA covers greater areas of cognitive
fields and looked at higher executive function, which is
not assessed by the MMSE. MoCA was easy to interpret
and discuss with other clinicians, compared to more
comprehensive cognitive tests such as the Cognistat or a
formal neuropsychological assessment. The multiple trans-
lations that are available for the MoCA means that it can
still be standardized. The score of the MoCA remains out
of 30 and therefore makes it a good objective measure for
test comparisons and discussion.
Our research suggests that the MMSE does not per-
form well as a screening instrument for mild cognitive
impairment due in part to the lack of sensitivity to
milder cognitive deficits with 10 patients (20%) achieving a
perfect score on MMSE compared to 3 patients (7%) on
MoCA. In addition, of the 43 patients who scor ed 24 or
more on MMSE, 25 patients (58%) scored 25 or less on
MoCA, indicating the presence of cogn itive impa irment.
Our study recommends that MoCA be used over the
widely used MMSE and suggests the need for more vali-
dation of the MoCA and MMSE in a population study
against other screening instruments. It is a simple stand
alone cognitiv e tool with superior sensitivity to MMSE. It
covers important cognitive domains and can be adminis-
tered generally within 15 minutes and the assessment fits
on one page. It is sen sitive to the pr esence of mild cogni-
tive impairment and is feasible for its use in clinical set-
tings. The MoCA promises to fill an urgent and unmet
need for brief tool capable of detecting patients with mild
cognitive impairment and distinguishing them from the
cognitively intact older person.

Comparison of the Folstein Mini Mental State Examination (MMSE) to the Montreal Cognitive Assessment
(MoCA) as a Cognitive Screening Tool in an Inpatient Rehabilitation Setting
42
5. Acknowledgements
We would like to acknowledge the efforts of Mr Martin
Oh and Ms Eve Wilson who assisted in performing the
cognitive assessments.
6. Conflicts of Interests
The authors state that there are no conflicts of interests
with regards to this research.
Patient Consent
Written consent obtained.
Ethics Approval
This study was conducted with the approval of the Hu-
man Resources and Ethics Committee Approval of Syd-
ney South West Area Health Service.
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