Is the Montreal Cognitive Assessment (MoCA) screening superior to the Mini-Mental State Examination (MMSE) in the detection of mild cognitive impairment (MCI) and Alzheimer’s Disease (AD) in the elderly?

Tiago C C Pinto¹, Leonardo Machado¹, Tatiana M Bulgacov¹, Antônio L Rodrigues-Júnior¹, Maria L G Costa¹, Rosana C C Ximenes¹, Everton B Sougey¹

With the prevalence of dementia increasing, especially in the geriatric population, there is a growing emphasis on early diagnosis and intervention. Mild cognitive impairment is a cognitive disorder with characteristics that fall between normal cognition and dementia (decline in cognitive abilities and functions), often serving as a precursor to dementia, with an annual conversion rate ranging from 6% to 31%. Therefore, diagnosing mild cognitive impairment is essential for preventative and therapeutic interventions in the early stages of disease. The Mini-Mental State Examination has been the most widely used screening instrument for decades; however, newer assessments like the Montreal Cognitive Assessment, developed in 2005, are now available.

This study is a systematic review that investigates whether the Montreal Cognitive Assessment outperforms the Mini-Mental State Examination in identifying mild cognitive impairment and Alzheimer’s disease among the elderly. The review evaluated 34 studies comparing these tools for detecting mild cognitive impairment and Alzheimer’s disease. Results show that the Montreal Cognitive Assessment is generally superior in identifying mild cognitive impairment, especially in elderly individuals with lower educational backgrounds. Additionally, the Mini-Mental State Examination demonstrated lower accuracy among highly educated elderly individuals due to a “ceiling effect,” where educated individuals with mild cognitive impairment tend to score similarly to cognitively healthy individuals. This difference is likely due to the design of the Montreal Cognitive Assessment, which includes more complex items, such as cube drawing and clock drawing, and a longer delay time for recall, making the test more challenging and thus more sensitive to mild cognitive impairment.

Some studies noted that adjusting the cut-off scores based on education level could further improve the accuracy of the Montreal Cognitive Assessment, particularly for individuals with less formal education. Both tests, however, are effective in detecting Alzheimer’s disease.

Reference:

Pinto, T. C. C., Machado, L., Bulgacov, T. M., Rodrigues-Júnior, A. L., Costa, M. L. G., Ximenes, R. C. C., & Sougey, E. B. (2019). Is the Montreal Cognitive Assessment (MoCA) screening superior to the Mini-Mental State Examination (MMSE) in the detection of mild cognitive impairment (MCI) and Alzheimer’s Disease (AD) in the elderly?. International psychogeriatrics, 31(4), 491–504. https://doi.org/10.1017/S1041610218001370

MoCA-vs.-MMSE

During my geriatrics rotation, I completed two site evaluations with Arti, PA-C from NYPQ. These evaluations were very informative as I presented patient cases and was tested on pharmacology cards that I created based on medications frequently encountered in my rotation. Each evaluation session was structured to encourage active learning and peer collaboration.

In my first evaluation, I presented a case involving a patient with a chronic cough, which we were investigating as a potential result of pneumonia or an exacerbation of congestive heart failure. After I shared my case, Arti assessed my pharmacology knowledge by reviewing the drug cards I had prepared. Following our individual presentations, Arti led a group discussion on a new case, which was a patient presenting with diarrhea. As a group, we worked through the steps of formulating a comprehensive workup. This interactive approach was highly beneficial, and I believe incorporating case discussions like these are valuable for all participants in the evaluation.

In my second evaluation, I presented another case, this time involving a patient for whom the geriatrics team was consulted on the internal medicine floor. This case was particularly memorable because it involved a patient with a history of recent falls. We conducted a thorough cognitive and neurological evaluation, which led us to consider several differential diagnoses, including various types of dementia and conditions like normal pressure hydrocephalus. The patient exhibited significant changes in cognition, memory, personality, ambulation, and coordination, making the case both complex and emotionally challenging due to the noticeable deterioration in their condition. This experience really showed me the diagnostic power of the physical exam in narrowing down differentials before ordering any additional labs or imaging.

As part of the second evaluation, I presented a research article comparing the efficacy of the Mini-Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) for diagnosing mild cognitive impairment. I chose this paper to introduce my peers to the MoCA, as MMSE is typically emphasized in school, yet other tools like MoCA can offer valuable insights into cognitive function.

To conclude the evaluation, Arti shared a set of multiple-choice questions with us, which we completed as a group. This activity was not only engaging but also excellent practice, as it reinforced key concepts and challenged us to think critically. I am grateful for the supportive and collaborative environment Arti fostered, which made each session a rewarding learning experience.

Acute epididymitis revisited: impact of molecular diagnostics on etiology and contemporary guideline recommendations

Adrian Pilatz¹, Hamid Hossain², Rolf Kaiser³, Annette Mankertz⁴, Christian G Schüttler⁵, Eugen Domann², Hans-Christian Schuppe⁶, Trinad Chakraborty², Wolfgang Weidner⁶, Florian Wagenlehner⁶

Acute epididymitis is a common infectious disease, with the etiology unknown in about 30% of cases, and the treatment is based on guidelines from studies published over 15 years ago. The purpose of this study is to investigate the etiology of acute epididymitis and provide data to guide antimicrobial therapy and clinical management.

Guidelines state that in young, sexually active men with epididymitis, Chlamydia trachomatis is the most common pathogen, whereas in older men with benign prostatic hyperplasia or other urinary issues, uropathogens such as Escherichia coli are most likely involved. However, this study found that enteric pathogens were responsible for most cases, including those in patients under 35 years of age.

According to these results, the assumption that young men primarily harbor sexually transmitted infections is not accurate, as enteric pathogens were identified in one-third of the cases. This study challenges the conventional approach of linking STIs to patients under 35 years old and enteric pathogens to those over 35. Although a sexual history suggestive of STIs was significantly associated with the actual presence of STIs, about half of STI pathogens were detected in sexually active patients without a history suspicious for STIs. This shows the importance of not only asking for a sexual history but also screening all sexually active patients for STIs.

Lastly, the study’s susceptibility assessments indicated that more than 85% of bacterial strains were susceptible to both fluoroquinolones and third-generation cephalosporins. Considering the lack of antichlamydial activity in third-generation cephalosporins, the study recommends fluoroquinolones with antichlamydial activity as the preferred therapy. This study presents a different approach to managing and treating acute epididymitis.

Reference:

Pilatz, A., Hossain, H., Kaiser, R., Mankertz, A., Schüttler, C. G., Domann, E., Schuppe, H. C., Chakraborty, T., Weidner, W., & Wagenlehner, F. (2015). Acute epididymitis revisited: impact of molecular diagnostics on etiology and contemporary guideline recommendations. European urology, 68(3), 428–435. https://doi.org/10.1016/j.eururo.2014.12.005

Acute-Epididymitis-Revisited-Etiology-and-Guideline-Recommendations