Previous PICO question RT 2 WK 1

Clinical Question: As in the past, please briefly outline the scenario and state your clinical question as concisely and specifically as possible

72 y/o AA female w/ PMHx of PTSD, HTN, and DM2 dropped off at the Adult day health center (ADHC) by daughter. Staff noticed the patient was not interacting with other members of the daycare center and seemed a little confused. The provider asks me to screen the Pt for cognitive impairment and hands me two sheets one was a Mini mental status exam (MMSE), and the other The Montreal Cognitive Assessment. She says choose one to assess the patient.

PICO Question:

Identify the PICO elements – this should be a revision of whichever PICO you have already begun in a previous week

Which is the better tool to screen for MCI in older adults (>60 y/o) MOCA or MMSE?

Search Strategy:

Database	Terms	Filter	Articles
PubMed	Mild cognitive impairment MOCA or MMSE elderly	<10yrs, humans, reviews	114
Science direct	MCI MOCA or MMSE	<5 years, open access	43
Cochrane	MCI MOCA or MMSE	none	35

 

Articles Chosen

The following articles were chosen because they are all systematic reviews and/or meta-analyses and are of the highest level of evidence per the evidence pyramid utilized in Evidence Based Medicine.

Is the Montreal Cognitive Assessment (MoCA) test better suited than the Mini-Mental State Examination (MMSE) in mild cognitive impairment (MCI) detection among people aged over 60? Meta-analysis. 

Ciesielska N, Sokolowski R, Mazur E, Podhorecka M, Polak-Szabela A, Kedziora-Kornatowska K. Is the Montreal Cognitive Assessment (MoCA) test better suited than the Mini-Mental State Examination (MMSE) in mild cognitive impairment (MCI) detection among people aged over 60? Meta-analysis. Psychiatr Pol. 2016;50(5):1039–1052. doi: 10.12740/PP/45368 PMID:27992895

LINK:

http://psychiatriapolska.pl/uploads/images/PP_5_2016/ENGver1039Ciesielska_PsychiatrPol2016v50i5.pdf

Abstract

Objectives: Screening tests play a crucial role in dementia diagnostics, thus they should be very sensitive for mild cognitive impairment (MCI) assessment. Nowadays, the Mini Mental State Examination (MMSE) is the most commonly used scale in cognitive function evaluation, albeit it is claimed to be imprecise for MCI detection. The Montreal Cognitive Assessment (MoCA), was created as an alternative method for MMSE. Aim. MoCA vs. MMSE credibility assessment in detecting MCI, while taking into consideration the sensitivity and specificity by cut-off points.

Methods : A systematic literature search was carried out by the authors using EBSCO host Web, Wiley Online Library, Springer Link, Science Direct and Medline databases. The following medical subject headings were used in the search: mild cognitive impairment, mini-mental state examination, Montreal cognitive assessment, diagnostics value. Papers which met inclusion and exclusion criteria were chosen to be included in this review. At the end, for the evaluation of MoCA 20, and MMSE 13 studies were qualified. Research credibility was established by computing weighted arithmetic mean, where weight is defined as population for which the result of sensitivity and specificity for the cut-off point was achieved. The cut-offs are shown as ROC curve and accuracy of diagnosis for MoCA and MMSE was calculated as the area under the curve (AUC).

Results: ROC curve analysis for MoCA demonstrated that MCI best detection can be achieved with a cut-off point of 24/25 (n = 9350, the sensitivity of 80.48% and specificity of 81.19%). AUC was 0.846 (95% CI 0.823-0.868). For MMSE, it turned out that more important cut-off was of 27/28 (n = 882, 66.34% sensitivity and specificity of 72.94%). AUC was 0.736 (95% CI 0.718-0.767).

Conclusions: MoCA test better meets the criteria for screening tests for the detection of MCI among patients over 60 years of age than MMSE.

 

Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis 

Tsoi KKF, Chan JYC, Hirai HW, Wong SYS, Kwok TCY. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. JAMA Intern Med. 2015;175(9):1450–1458. doi:10.1001/jamainternmed.2015.2152

LINK: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2301149

Abstract

Importance: Dementia is a global public health problem. The Mini-Mental State Examination (MMSE) is a proprietary instrument for detecting dementia, but many other tests are also available.

Objective : To evaluate the diagnostic performance of all cognitive tests for the detection of dementia.

Data Sources:  Literature searches were performed on the list of dementia screening tests in MEDLINE, EMBASE, and Psycho INFO from the earliest available dates stated in the individual databases until September 1, 2014. Because Google Scholar searches literature with a combined ranking algorithm on citation counts and keywords in each article, our literature search was extended to Google Scholar with individual test names and dementia screening as a supplementary search.

Study Selection: Studies were eligible if participants were interviewed face to face with respective screening tests, and findings were compared with criterion standard diagnostic criteria for dementia. Bivariate random-effects models were used, and the area under the summary receiver-operating characteristic curve was used to present the overall performance.

Main Outcomes and Measures: Sensitivity, specificity, and positive and negative likelihood ratios were the main outcomes.

Results:  Eleven screening tests were identified among 149 studies with more than 49 000 participants. Most studies used the MMSE (n = 102) and included 10 263 patients with dementia. The combined sensitivity and specificity for detection of dementia were 0.81 (95% CI, 0.78-0.84) and 0.89 (95% CI, 0.87-0.91), respectively. Among the other 10 tests, the Mini-Cog test and Addenbrooke’s Cognitive Examination–Revised (ACE-R) had the best diagnostic performances, which were comparable to that of the MMSE (Mini-Cog, 0.91 sensitivity and 0.86 specificity; ACE-R, 0.92 sensitivity and 0.89 specificity). Subgroup analysis revealed that only the Montreal Cognitive Assessment had comparable performance to the MMSE on detection of mild cognitive impairment with 0.89 sensitivity and 0.75 specificity.

Conclusions and Relevance:  Besides the MMSE, there are many other tests with comparable diagnostic performance for detecting dementia. The Mini-Cog test and the ACE-R are the best alternative screening tests for dementia, and the Montreal Cognitive Assessment is the best alternative for mild cognitive impairment.

 

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?

Dong Y, Lee WY, Basri NA, Collinson SL, Merchant RA, Venketasubramanian N, Chen CL. The Montreal cognitive assessment is superior to the mini-mental state examination in detecting patients at higher risk of dementia. Int Psychogeriatr. 2012;24(11):1749–1755. doi:

10.1017/S1041610212001068.PMID:22687278

LINK: https://www.ncbi.nlm.nih.gov/pubmed/22687278

Abstract:

Objective: To compare the accuracy of Mini-Mental State Examination (MMSE) and of the Montreal Cognitive Assessment (MOCA) in tracking mild cognitive impairment (MCI) and Alzheimer’s Disease (AD).

Method: A Systematic review of the PubMed, Bireme, Science Direct, Cochrane Library, and Psyc Info databases was conducted. Using inclusion and exclusion criteria and staring with 1,629 articles, 34 articles were selected. The quality of the selected research was evaluated through the Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2).

Result: More than 80% of the articles showed MOCA to be superior to MMSE in discriminating between individuals with mild cognitive impairment and no cognitive impairment. The area under the curve varied from 0.71 to 0.99 for MOCA, and 0.43 to 0.94 for MMSE, when evaluating the ability to discriminate MCI in the cognitively healthy elderly individuals, and 0.87 to 0.99 and 0.67 to 0.99, respectively, when evaluating the detection of AD. The AUC mean value for MOCA was significantly larger compared to the MMSE in discriminating MCI from control [0.883 (CI 95% 0.855-0.912) vs MMSE 0.780 (CI 95% 0.740-0.820)

p<0.001].

Conclusion: The screening tool MOCA is superior to MMSE in the identification of MCI, and both tests were found to be accurate in the detection of AD.

 

Recall Tests Are Effective to Detect Mild Cognitive Impairment: A Systematic Review and Meta-analysis of 108 Diagnostic Studies.

Tsoi KK, Chan JY, Hirai HW, Wong A, Mok VC, Lam LC, Kwok TC, Wong SY. Recall tests are effective to detect mild cognitive impairment: A systematic review and meta-analysis of 108 diagnostic studies. J Am Med Dir Assoc. 2017;18(9):807. doi: 10.1016/j.jamda.2017.05.016

PMID: 28754516

LINK: https://www.jamda.com/article/S1525-8610(17)30295-5/fulltext

 Abstract:

 Background: Mild cognitive impairment (MCI) is a prevalent symptom associated with the increased risk of dementia. There are many cognitive tests available for detection of MCI, and investigation of the diagnostic performance of the tests is deemed necessary.

Objective: This study aims to evaluate the diagnostic performance of different cognitive tests used for MCI detection.

Data sources: A list of cognitive tests was identified in previous reviews and from online search engines. Literature searches were performed on each of the cognitive tests in MEDLINE, Embase, and PsycINFO from the earliest available dates of individual databases to December 31, 2016. Google Scholar was used as a supplementary search tool.

Study selection: Studies that were used to assess the diagnostic performance of the cognitive tests were extracted with inclusion and exclusion criteria. Each test’s performance was compared with the standard diagnostic criteria. Bivariate random effects models were used to summarize the test performance as a point estimate for sensitivity and specificity, and presented in a summary receiver operating characteristic curve. Reporting quality and risk of bias were evaluated.

Results: A total of 108 studies with 23,546 participants were selected to evaluate 9 cognitive tests for MCI detection. Most of the studies used the Mini-Mental State Examination (MMSE) (n = 58) and the Montreal Cognitive Assessment (MoCA) (n = 35). The combined diagnostic performance of the MMSE in MCI detection was 0.71 sensitivity [95% confidence interval (CI): 0.66-0.75] and 0.74 specificity (95% CI: 0.70-0.78), and of the MoCA in MCI detection was 0.83 sensitivity (95% CI: 0.80-0.86) and 0.75 specificity (95% CI: 0.69-0.80). Among the 9 cognitive tests, recall tests showed the best diagnostic performance with 0.89 sensitivity (95% CI: 0.86-0.92) and 0.84 specificity (95% CI, 0.79-0.89). In subgroup analyses, long- or short-delay recall tests have shown better performance than immediate recall tests.

Conclusions: Recall tests were shown to be the most effective test in MCI detection, especially for the population with symptoms of memory deterioration. They can be potentially used as the triage screening test for MCI in primary care setting. But when a patient shows cognitive impairments beyond memory deterioration, a more comprehensive test such as the MoCA should be used.

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc.)	Outcome(s) studied	Key Findings	Limitations and Biases
Article 1:  Ciesielska N, Sokolowski R, Mazur E, Podhorecka M, Polak-Szabela A, Kedziora-Kornatowska K.	Meta-analysis	Systematic search yielded 20 studies (11,952 participants) met inclusion criteria Participants were all >60 years of age systematic literature search was carried out by the authors using Medline, Wiley Online Library, Science Direct, Springer, EBSCO HOST and Google Scholar databases. All included studies: -Separated group of Healthy Controls (HC) and MCI group -Provided Statistical analysis of both groups’ demographic data; -Statistical evaluation of the diagnostic reliability of MoCA scale and MMSE for the MCI group vs. the control group. -The sensitivity, specificity of cut-off points for MoCA and MMSE for MCI group vs. HC.	Evaluated the statistical reliability of the screening assessment scales MoCA vs. MMSE for MCI diagnostics. The sensitivity and specificity of MoCA test in differentiating people with MCI vs. HC. Cut-off points for the MMSE and MoCA in detecting MCI vs. HC.	MoCA meets the criteria for screening tests for the detection of MCI in patients over 60 years of age better than MMSE. For MoCA: According to ROC curve analysis best cut-o point is 24/25, (sensitivity of 80.48%, specificity of 81.19%). AUC was 0.846 (95% CI: 0.823–0.868). For MMSE: Best cut-off point is 27/28 n = 882 (sensitivity of 66.34% and specificity of 72.94%). AUC was 0.736 (95% CI: 0.718–0.767) The odds ratio is in favor of MoCA, OR = 1.146 (95% CI: 1.116–1.176) Based off these result one may make the assumption that MoCA is better in detecting MCI than MMSE.	To analyze the sensitivity and specificity of MoCA for all the cut-off points, it was observed that -only 5 studies had data for eight or more cut-off points. -The remaining 16 studies included only data for the most reliable  according to the authors cut-off points. In evaluation of the MMSE reliability parameters based on cut-off points showed that : -13 out of 20 studies provide information regarding the sensitivity and specificity. -Only 2 studies reported results for 5 or more cut-off points. The lack of data for different cut-off points for MoCA, and  MMSE may have affected the survey weight for cut-off points other than the ones selected by the author as the best cut off points.
Article 2: Kelvin K. F. Tsoi, PhD; Joyce Y. C. Chan, MPH; Hoyee W. Hirai, MSc; Samuel Y. S. Wong, MD; Timothy C. Y. Kwok, MD, PhD	Meta -Analysis	Eleven screening tests were identified in 149 studies (49000 participants) published from 1989-Sept1, 2014,for patients-with dementia from U.S.,UK, Canada, and 30 other countries. Most studies used the MMSE (n = 102) and included 10,263 patients with dementia. Literature searches-performed on-dementia screening tests in MEDLINE, EMBASE, and PsychoINFO, Google scholar from-earliest available dates to September 1, 2014. Recruitment settings, participants were recruited: hospital (9.3%), clinic (32.4%), primary-care (12.0%), community (38.9%), other settings (7.4%).	Sensitivity, specificity, and positive and negative likelihood ratios were the main outcomes.	Combined sensitivity/specificity for detection of dementia were0.81 (95% CI, 0.78-0.84) and 0.89 (95% CI, 0.87-0.91), Specificity/sensitivity of -Mini-Cog, 0.91sensitivity 0.86specificity ACE-R, 0.92sensitivity 0.89specificity Subgroup analysis revealed: MoCA had sensitivity 0.89 (95% CI 0.84-0.92) and 0.75 specificity (95%CI 0.62-0.85) MMSE on detection of mild cognitive impairment 0.62 sensitivity (95% CI,0.52-0.71) specificity 0.87 (95%CI 0.80-0.92)	This study has several limitations. -First, the screening tests were not directly compared in the same populations Each study used different populations, and the inclusion criteria and prevalence of dementia varied. Second, only a few studies were included that showed head-to-head comparison between the screening tests, so the test performance could not be directly compared. -Third, the screening tests were translated into different languages, which may have unknown effects on the results. Fourth, it included studies that reported the diagnostic performance of screening tests for dementia. Studies that only reported the results of MCI or cognitive impairment but not dementia (cognitive impair- ment no dementia) were not included. Unpublished studies may not have been identified through the literature search in OVID databases, and publication bias may exist.
Article 3: Tiago C. C. Pinto, Leonardo Machado, Tatiana M. Bulgacov, Antônio L. Rodrigues- Júnior, Maria L. G. Costa, Rosana C. C. Ximenes, and Everton B. Sougey	Systematic-Review	Systematic review of the PubMed, Bireme, Science Direct, Cochrane Library, and PsycInfo databases More than 65% of the studies selected were conducted within the last five years Using inclusion and exclusion criteria and staring with 1,629 articles, 34 articles were selected. Quality of the selected research was evaluated through the Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2). The Area under the curve (AUC) calculated from the ROC curve, was used to compare the diagnostic accuracy of MoCA and MMSE. Most of the studies were conducted in the Asian Continent (20/34), 24% of the research was conducted on elderly individuals from China (8/34), one of the countries with the largest popula- tion in the world aged over 60.	Accuracy of MOCA (AUC) and sensitivity/specificity – control vs MCI Accuracy of MOCA (AUC) and sensitivity/specificity – control vs AD Accuracy of MMSE (AUC) and sensitivity/specificity – of control vs MCI Accuracy of MMSE (AUC) and sensitivity/specificity – control vs AD CUT OFF MOCA – control vs MCI control vs AD	Twenty-five articles (80.6%) showed superiority of MoCA to MMSE in discriminating individuals with mild cognitive impairment and no mild cognitive impairment. Fourteen studies (58.3%), demonstrated similar accuracy between MoCA and MMSE in the detec- tion of mild dementia, while the other 10 studies (41.7%) showed MoCA was superior to MMSE for this detection AUC varied from 0.71 to 0.99 for MoCA, and 0.43 to 0.94 for MMSE, when evaluating the ability to distinguish MCI in the cognitively healthy elderly individuals. discriminative power of cogni- tively healthy elderly individuals from those with mild Alzheimer’s Disease, the AUC of MoCA varied from 0.87 to 0.99, while the AUC of MMSE varied from 0.67 to 0.99. The AUC mean value for MoCA was significantly larger compared to the MMSE in discriminating MCI from control [0.883 (CI 95% 0.855-0.912) vs MMSE 0.780 (CI 95% 0.740-0.820) p < 0.001]. The cut- off point of MoCA varied within the studies, from 13/14, in the elderly with low education to 28/29 The most frequent cut-off point to detect MCI was 21/22 and 19/20 to detect AD. With low formal education, lower values of the cut-off point were found to attain a more accurate diagnosis All the studies presented a low risk of bias and high applicability regarding to the index test of the QUADAS The study proposed that MoCA be chosen in over the MMSE as the test for tracking of MCI.	Four studies that presented results stratified per education found lower cut-off points for elderly individuals who have lower formal education, -lower accuracy in MMSE was found in the elderly group with higher formal education due to the ceiling effect that occurs in elderly individuals with higher education when administering MMSE. Even those with the diagnosis of MCI and mild AD are able to achieve performance similar to cognitively healthy elderly individuals, thus decreasing the accuracy of the test
Article 4: Kelvin K.F. Tsoi PhD,  Joyce Y.C. Chan MPH,  Hoyee W. Hirai MSc , Adrian Wong PhD, Vincent C.T. Mok MD, Linda C.W. Lam MD, Timothy C.Y. Kwok MD, Samuel Y.S. Wong MPH, MD.	Systematic review and Meta-analysis	A total of 108 studies with 23,546 participants were selected to evaluate 9 cognitive tests for MCI detection.   Most of the studies used the MMSE (n =58) and the  MoCA(n=35).   Participants: were 55 years old and older	-Sensitivity and specificity of each cognitive test using a bivariate random effects model -Diagnostic odds ratio -for performance across a different threshold of cutoff values. -Summary estimates of sensitivity and specificity along with corresponding 95% CIs and prediction region. HSROC curve (AUC) -diagnostic performance. Hessian matrix of bivariate random effects- to estimate the pooled sensitivity and specificity. Summary receiver operating characteristic (SROC) curve – for summary estimates of sensitivities and specificities with the AUC as a summary statistic. Statistical heterogeneity among the trials assessed by I2, –percentage of total variation across studies due to the heterogeneity. Subgroup analyses —of cognitive tests with different versions and different types of criterion standard.	The combined diagnostic performance of the MMSE in MCI detection was 0.71 sensitivity [95% CI: 0.66-0.75] and 0.74 specificity (95% CI: 0.70-0.78), and of MoCA in MCI detection was 0.83 sensitivity (95% CI: 0.80-0.86) and 0.75 specificity (95% CI: 0.69-0.80). Among the 9 cognitive tests, recall tests showed the best diagnostic performance with 0.89 sensitivity (95% CI: 0.86-0.92) and 0.84 specificity (95% CI, 0.79-0.89). In subgroup analyses, long- or short-delay recall tests have shown better performance than immediate recall tests. Recall tests were shown to be the most effective test in MCI detection, especially for the population with symptoms of memory deterioration. When a patient shows cognitive impairments beyond memory deterioration, a more comprehensive test such as the MoCA should be used.	First, some levels of clinical heterogeneity were observed during data extraction. The results might have come from different versions of cognitive tests, and some of the tests were translated into different languages. Test results may still have some degrees of variations. -subgroup analyses for different versions of cognitive tests were performed but there were a limited number of available studies. – the comparison across different types of cognitive tests used combined data from studies of different participants, because only some studies conducted comparison on the same group of participants. The results of this study thus may deviate toward the estimate on a group of participants who could take all of the cognitive tests. -unpublished studies might not have been identified through the literature searches in the OVID databases. Even though they extended the search to Google Scholar, the publication bias cannot be eliminated.

 

Conclusion(s):

Article 1:

MoCA test better meets the criteria for screening tests for the detection of MCI among patients over 60 years of age than MMSE.

Article 2:

The Mini-Cog test and the ACE-R are the best alternative screening tests for dementia, and the Montreal Cognitive Assessment is the best alternative for mild cognitive impairment since the subgroup analysis revealed that only the Montreal Cognitive Assessment had comparable performance to the MMSE on detection of mild cognitive impairment with 0.89 sensitivity and 0.75 specificity.

Article 3:

The screening tool MoCA is superior to MMSE in the identification of MCI, and both tests were found to be accurate in the detection of AD.

Article 4:

 The MoCA should be used in patients with cognitive impairments beyond memory deterioration.

Overarching conclusion:

MoCA is more efficient in detecting MCI in elderly >60 when compared to MMSE.

Clinical Bottom Line:

MCI is a reduction in cognitive functions, such as memory, attention, language and visual/spatial skills. Symptoms of MCI are not severe enough to interfere with daily life, which means it cannot normally be categorized as dementia. Patients with MCI are three to five times more likely to develop some form of dementia compared to someone without MCI. Some studies have suggested that there may be ways to reduce the rate of decline in cognitive ability and make it less likely that it progresses to a form of dementia. This give us more reason to detect MCI at an early stage and explore some of the patient options of preventing progression of MCI with them. Detection can also allow for patients at higher risk of dementia to plan ahead in the case they do develop dementia.

After reviewing the available literature, it is evident that the MMSE has been the most commonly used screening test to assess for problems with ​memory and other cognitive functions. Since there are many other screening tests available for detection of the decrease in cognitive functions there is a need to evaluate the efficiency of such tests in different populations. The following articles explored the efficiency of different screening test that are available in detecting MCI in the elderly.

The first article I chose was an up to date Meta-analysis (2016) that looked a large population (n=11,952). The age of participants was >65, which allowed proper representation of the population of interest. This was the Meta-analysis, which took into account the statistical reliability of the screening assessment scales MoCA vs. MMSE for MCI diagnostics. The study provided clear explanation of the inclusion and exclusion selection criteria, and the authors recognized the limitations of the study.

The second study was a Meta-analysis (2015), and was published in Jama Internal Medicine, which gave it high credibility. This study compared the diagnostic performance of MCOA, MMSE, and a few others. The only thing this article was lacking was the inclusion criteria and did not specifically include the age group of >60, but they did a very good job with reporting the specific details of all articles. The following were reported by this study for all articles.

• year of publication, study location, number of participants included
• mean age of participants, percentage of male participants,
• type of dementia, recruitment site, number of participants with dementia or mild cognitive impairment (MCI)
• diagnostic criteria, cutoff values, sensitivity, specificity, and true-positive, false-positive, true-negative, and false-negative likelihood ratios

The study concluded that the MOCA had better diagnostic performance for MCI than all other screening tests.

Article 3, was a systematic review published in 2012, and it analyzed the effectiveness of MOCA and MMSE in distinguishing MCI and Alzheimer’s Disease. This study looked at a population similar to my patient in terms of age, and it aimed to evaluate the accuracy of the two tests in tracking MCI and AD in elderly individuals. The article proposed that MOCA be chosen in relation to MMSE as the test for cognitive tracking in the elderly, mainly for the tracking of MCI.

Article 4, was a Systematic review/ Meta-analysis (2017) of 23,546 participants (aged 55 to 84 years), which evaluated 9 cognitive tests for MCI detection. Even though the age of the participants in this study was not exactly over 65, it still included population of 55 years old and older, and it was a well conducted study.  The strength of this study was that it included literature from 108 studies that recruited participants from all over the world, making it a representable sample of a larger more diverse population. The study did a good job in recognizing its limitations, adjusted for heterogeneity to exclude heterogeneity effects, and performed subgroup analysis on different versions of cognitive test to account for variation. This study found the MoCA test to be more sensitive and specific then the MMSE test in detection of MCI. It was concluded that when patients show cognitive impairments beyond memory deterioration, a more comprehensive test such as the MoCA be used to confirm the severity of the cognitive impairments.

According to researchers MCI has been understood as a transitional stage between the natural aging and dementia, early detection of MCI can be essential in slowing down its progression and development into dementia. All studies included are well conducted and of highest evidence with results that are in agreement of MoCA being more effective in detecting MCI than MMSE. I strongly believe it would be acceptable to use the MOCA over the MMSE to screen elderly patients who seem to be at higher risk of MCI or, are showing signs of decline of cognitive functions over the MMSE.