General Hospital Psychiatry 37 (2015) 476–480
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General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
The Montreal Cognitive Assessment as a preliminary assessment tool in general psychiatry Validity of MoCA in psychiatric patients J. Gierus, M.A. a,b,⁎, A. Mosiołek, M.D., Ph.D. a,b, T. Koweszko, M.A. a,b, P. Wnukiewicz, M.A. a, O. Kozyra, M.A. a, A. Szulc, M.D., Ph.D. a,b a b
The Prof. Jan Mazurkiewicz Mazovia Specialist Health Centre, Pruszków, Poland Clinic of Psychiatry, Department of Health Sciences, Medical University of Warsaw, Pruszków, Poland
a r t i c l e
i n f o
Article history: Received 17 July 2014 Revised 18 May 2015 Accepted 22 May 2015 Keywords: Montreal Cognitive Assessment (MoCA) Cognitive assessment Psychiatric patients
a b s t r a c t Objective: The aim of the presented research was to obtain the initial data regarding the validity of Montreal Cognitive Assessment (MoCA) in diagnosing cognitive impairment in psychiatrically hospitalized patients. Method: The results in MoCA obtained from 221 patients were analyzed in terms of proportional participation of patients with particular diagnosis in three result ranges. In 67 patients, additional version of the scale was also used. Comparative analysis of average results in particular diagnostic groups (organically based disorders, disorders due to psychoactive substance use, psychotic disorders, neurotic disorders and personality disorders) was also carried out, as well as an analysis of the scale’s accuracy as a diagnostic test in detecting organic disorders. Results: The reliability of the test measured with between tests correlation coefficient rho=0.92 (P=.000). Significant differences between particular diagnoses groups were detected (J–T=13736; P=.000). The cutoff points of 23 turned out to have a satisfactory sensitivity and specificity (0.82 and 0.70, respectively) in diagnosing organically based disorders. The area below the receiver operating characteristic curve (AUC=0.854; P=.000) suggests that MoCA has a satisfactory value as a classifier. Conclusion: The initial data suggest MoCA’s high value in prediction of future diagnosis of organically based disorders. The initial results obtained in particular group of diagnoses support construct validity of the method. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Diagnosing cognitive functions appears to be at least as important for the psychiatric patients functioning as axial symptoms of psychic disorders [1–4]. The occurrence of cognitive disorders depending on their grounds determines recommendation for neurological (organically based disorders) or psychiatric (schizophrenia, affective disorders) rehabilitation. Two out of six symptom levels of schizophrenia understood as mind entropy [5] concern cognitive functioning: procedural sphere (executive functions and motor capacity) and neuropsychological variables (attention, memory and concentration impairment). In clinical practice, the batteries directed at patients with specific diagnoses, such as MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) or TURNS (Treatment Units for Research on Neurocognition and Schizophrenia), are used [6]. However, the use of these methods often requires computer equipment, specialized trainings for the diagnosticians and at least 90–120 min of time [7,8]. Screening methods that take approximately 15–20 min, such as B-CATS (Brief Cognitive Assessment Tool for ⁎ Corresponding author. Clinic of Psychiatry, Department of Health Sciences, Medical University of Warsaw, Pruszków, Poland, Partyzantów 2/4, 05-802 Pruszków, Poland. Tel.: +48-22-758-63-71; fax: +48-22-758-75-70. E-mail address: [email protected] (J. Gierus). http://dx.doi.org/10.1016/j.genhosppsych.2015.05.011 0163-8343/© 2015 Elsevier Inc. All rights reserved.
Schizophrenia), are often meant for patients with a specific diagnosis or, like in case of The Mini-Mental State Examination (MMSE), are designed for the diagnosis of more severe cognitive impairment [8–11]. This is why tools with confirmed diagnostic value in various neurological and psychiatric disorders become useful in screening diagnostics since they enable the diagnostician to quickly build a rough image of patients’ cognitive functioning. One of such tools is the Montreal Cognitive Assessment (MoCA). Majority of research regarding validity of the scale concerns mild cognitive impairment (MCI) and dementia, although its structure suggests very broad scope of possible use. The article concerns chosen aspects of MoCA’s scale validity in psychiatrically hospitalized patients. The MoCA has been designed for screening detection of MCI displaying a more favorable sensitivity and specificity in diagnosis than MMSE [12]. The scale is useful in detecting cognitive disorders with vascular origin, cerebral cancer metastases, brain tumors, Huntington’s disease and Parkinson’s disease [12–15], as well as the course of schizophrenia [16,17] and sleep disorders [18]. Recently, there has been some research published suggesting MoCA’s high diagnostic value in terms of cognitive impairment in patients with severe mental illness (SMI). A total of 89% of patients with SMI obtained less than 26 points, which was accepted as the cutoff point. The specificity for this point was 61%. MoCA turned out to be a better classifier than BACS (Brief Assessment of Cognition in Schizophrenia) [19]. In different studies, cognitive
J. Gierus et al. / General Hospital Psychiatry 37 (2015) 476–480 Table 1 Average MoCA results in different diagnostic groups. Diagnosis
N
M
SD
Organically based disorders Disorders due to psychoactive substance use Psychotic disorders Affective disorders Neurotic disorders Personality disorders
23 25 77 44 28 24
17.78 23.56 22.60 24.39 26.07 27.83
4.562 2.451 5.014 3.418 2.340 2.078
disorders have been confirmed in 81.3% of patients whose MoCA score suggested such disorders [20]. In Poland, there are two versions of MoCA scale: the adaptation of the first English basic version [21] as well as the adaptation of the English version 7.2 [22]. The current article describes the chosen aspects of MoCA’s construct validity in the group of patients hospitalized in a psychiatric hospital. It also deals with the concurrent validity and criterion validity of MoCA scale in detecting patients with organically based diagnosis compared to the rest of patients. 2. Materials and methods 2.1. The source of data A total of 221 patients aged 18–82 years, hospitalized in general psychiatric unit in {blind review}, were examined. A total of 45.2% (N= 100) of the subjects were males, while 54.8% (N= 121) were females. In the analyzed sample, 10.4% (N=23) were patients with organically based disorders, 11.3% (N=25) were patients with disorders due to psychoactive substance use, 34.8% (N=77) were patients with psychotic disorders, 19.9% (N=44) were patients with affective disorders, 12.7% (N=28) were patients with neurotic disorders and 10.9% (N=23) were patients hospitalized for a crisis caused by personality disorders. There were no differences in between the sexes in terms of average results in MoCA scale (Mann–Whitney U=5458.00; P=.210). A total of 67 patients (37 males and 30 females) were additionally examined with an alternative version of MoCA 7.2. The order of the execution of each test by the patients was random. 2.2. Measurement The results of 221 patients of {blind review} in the course of diagnostic process were analyzed, and then after the end of the process, the data were assigned to each diagnostic group based on International Statistical Classification of Diseases, 10th Revision (ICD-10) criteria: (1) organically based disorders, (2) mental and behavioral disorders due to psychoactive substance use, (3) psychotic disorders, (4) affective disorders, (5) neurotic disorders and (6) personality disorders. The organically based disorders were diagnosed based on brain damage or significant atrophy displayed by computed tomography or magnetic resonance imaging, consistent in terms of occurrence and time with psychiatric symptoms, changes in electroencephalogram and/or cognitive disorders diagnosed by MMSE, Trail Making Test A and B, Rey Auditory Verbal Learning Test and Rey-Osterrieth Complex Figure Test. Mental and behavioral disorders due to psychoactive substance use, psychotic, affective and neurotic disorders were diagnosed by clinical interview conducted by a psychiatrist and a psychologist as well as M.I.N.I. International Neuropsychiatric Interview and psychiatric observation. Personality disorders’ diagnosis was based on an interview
477
conducted by a psychiatrist and a psychologist, observation and the clinical interview Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders II (SCID-II). The data obtained by SCID-II interview were verified in terms of its coefficiency with ICD-10 criteria. None of the subjects was excluded from the group due to inconsistency of the criteria. All diagnoses were supervised by head of hospital ward. PASW Statistics 18 software was used to analyze the data. 3. Results 3.1. Concurrent validity The concurrent validity of the method was verified by calculating the overall scale results correlation coefficient with results of collateral Polish version of MoCA 7.2 test, which is the adaptation of the English version MoCA 7.2 scale. It was crated with the emphasis put on receiving the highest possible resemblance of tasks to the basic version. The Rho-Spearman correlation coefficient between the two versions of MoCA scale was Rho=0.926 (P=.000). The differences between the two tests turned out to be insignificant confirming the nonparametric test’s value for Wilcoxon-dependent data (Z=−0.523; P= .601). Nonparametric statistics were used because distribution of differences between the first and the second measurement was not normal (Shapiro–Wilk W=0.912, P=.001; kurtosis=3.324). 3.2. The chosen aspects of construct validity for psychiatric diagnoses In the analyzed group, the particular diagnoses groups were specified and the descriptive statistics were calculated among them. If MoCA’s results actually reflect the current knowledge, patients with organically based and brain disorders should score the lowest in the considered groups while patients with schizophrenia should score higher than those with organic disorders yet simultaneously lower than patients with affective, anxiety or personality disorders. Such predictions regarding MoCA’s test results are based on the assumption that cognitive deficits in psychic disorders in particular patients have rarely deep and global character, covering merely several cognitive functions [23–25]. The results can be found in Table 1 below. The significance of intergroup differences was verified by the nonparametric Jonckheere–Terpstra test for several dependent samples. The obtained result for six of the compared groups suggests significant differences between average results in diagnostic groups (Table 2). Since the MoCA results distribution in the examined groups deviated from normal, the post hoc analysis was conducted with the use of Mann–Whitney U test. The results of patients from the organic disorders groups turned out to be the lowest and they significantly differed from average results of other clinical groups. Average results of patients with psychotic disorders, disorders due to psychoactive substance use and affective disorders did not differ from each other. They were, however, significantly higher than the results of patients with organically based disorders and lower than those of patients with neurotic and personality disorders. No differences were found between the average results in MoCA in patients with personality and neurotic disorders (Table 3). 3.3. Sensitivity, specificity and accuracy in detection of organically based disorders MoCA’s overall result validity as a classifier in psychiatric patients group was verified through receiver operating characteristic (ROC) curve: (1) in distinguishing organically based disorders from other
Table 2 Nonparametric statistics for K dependent samples (N=221) in Jonckheere–Terpstra test. Observed J-T statistics
Mean J-T statistics
Standard deviation of J-T statistics
Standard. J-T statistics
Asymptotic significance (two tailed)
13,736.000
9615.500
531.889
7.747
0.000
478
J. Gierus et al. / General Hospital Psychiatry 37 (2015) 476–480
Table 3 MoCA results — Differences between individual groups and tests of statistical significance of the differences (Mann–Whitney U test). A
B
Difference in means (A−B)
Mann–Whitney U significance
F00-F09
F10-F19 F20-F29 F30-F39 F40-F49 F60 F00-F09 F20-F29 F30-F39 F40-F49 F60 F00-F09 F10-F19 F30-F39 F40-F49 F60 F00-F09 F10-F19 F20-F29 F40-F49 F60 F00-F09 F10-F19 F20-F29 F30-F39 F60 F00-F09 F10-F19 F20-F29 F30-F39 F40-F49
−5.777⁎ −4.815⁎ −6.604⁎ −8.289⁎ −10.051⁎ 5.777⁎
0.000 0.000 0.000 0.000 0.000 0.000 0.643 0.259 0.001 0.000 0.000 0.643 0.080 0.001 0.000 0.000 0.259 0.080 0.034 0.000 0.000 0.001 0.001 0.034 0.004 0.000 0.000 0.000 0.000 0.004
F10-F19
F20-F29
F30-F39
F40-F49
F60
.963 -.826 −2.511 −4.273⁎ 4.815⁎ -.963 −1.789 −3.474⁎ −5.236⁎ 6.604⁎ .826 1.789 −1.685 −3.447⁎ 8.289⁎ 2.511 3.474⁎ 1.685 −1.762 10.051⁎ 4.273⁎ 5.236⁎ 3.447⁎ 1.762
Table 5 Sensitivity and specificity of particular raw MoCA data. Positive if less than or equal toa 5.00 8.00 10.50 11.50 12.50 13.50 14.50 15.50 16.50 17.50 18.50 19.50 20.50 21.50 22.50 23.50 24.50 25.50 26.50 27.50 28.50 29.50 31.00
Sensitivity
1−Specificity
.000 .000 .087 .087 .130 .174 .217 .304 .435 .522 .522 .696 .739 .783 .826 .826 .957 .957 .957 1.000 1.000 1.000 1.000
.000 .005 .005 .010 .015 .015 .025 .035 .040 .066 .091 .121 .172 .247 .303 .374 .475 .556 .636 .753 .843 .955 1.000
The test result variable(s): MoCA result has at least one tie between the positive actual state group and the negative actual state group. a The smallest cutoff value is the minimum observed test value minus 1, and the largest cutoff value is the maximum observed test value plus 1. All the other cutoff values are the averages of two consecutive ordered observed test values.
F00-F09, organically based disorders; F10-F19, disorders due to psychoactive substance use; F20-F29, psychotic disorders; F30-F39, affective disorders; F40-F49, neurotic disorders; F60, personality disorders.
combined patients groups and (2) in differentiating patients with personality disorders from other combined patients. The groups were chosen based on the expected extreme results compared with other groups. Next, ROC curves in distinguishing organically based disorders from other groups separately (substance use, anxiety and personality disorders) were drawn. The area below the ROC curve (AUC=0.854) indicates an initially satisfactory classifier’s value for the organically based disorders screening test. Moreover, the area below the ROC curve indicates satisfactory diagnostic value of MoCA (AUC=0.839) as a test for selecting patients with personality disorders from other groups (Table 4). The abovementioned data suggest that MoCA’s overall result is the most accurate in distinguishing organically based disorders from anxiety and personality disorders and least accurate in terms of differentiating these from the psychotic disorders. The analysis of possible cutoff points suggests that the raw data lower than 23 points appear to have a satisfactory sensitivity and specificity in distinguishing patients with organically based disorders from the other patients groups (0.82 and 0.70, respectively) (Table 5). After analyzing the observations including wrong diagnoses, it turned out that, out of the 31 false diagnoses, 22 concerns false-positive diagnoses in patients with long course of schizophrenia. The test’s low specificity is likely to be the result of higher value of false-positive diagnoses. In order to illustrate the different diagnosis groups’ distribution, the percentage data were grouped in point ranges based on the average and standard deviation.
Table 6 shows the proportional participation of patients with particular diagnoses in three result ranges (0–19; 20–26; 27–30). The results in particular groups distribute in a different and specific way, and at the same time, such configuration suggests that many patients with psychotic disorders score similarly to patients with organically based disorders. Very common score in all of the groups is the result between 20 and 26 points. 4. Discussion If we look at particular groups of disorders, one might expect that patients with organic disorders achieve the lowest results among all of the groups [26,27]. In this case, the largest group of patients scored below 19 and merely 4% scored 27 points and higher. In patients with disorders due to psychoactive substance use, one might expect a diverse lowering of cognitive functions, merely reaching the global or profound level [28,29], and this also suggests proportional distribution of patients in the results’ ranges — 84% of the subjects obtained results of 20–26 points. Patients with psychotic disorders might score differently in terms of cognitive functions and this fact might depend on the time and the course of the illness [19,25]. In this case, the largest group includes patients with scores between 20 and 26 points and two slightly smaller groups distribute almost equally in the remaining ranges. This might be the reflection of the fact that there were patients with different time span of the illness and the level of functioning among the subjects also differed. The majority of the subjects with affective disorders scored between 20 and 26 points and the result might suggest mild lowering of cognitive functions that may also appear consistent with the literature and existing studies [30,31]. In patients with neurotic and personality disorders, the most favorable results were expected and this expectation was confirmed: none of the patients in these groups scored in the
Table 4 Area under ROC curve for differentiating organically based disorders from other groups of diagnoses. Organically based disorders vs. substance use disorders
Organically based disorders vs. psychotic disorders
Organically based disorders vs. mood disorders
Organically based disorders vs. anxiety disorders
Organically based disorders vs. personality disorders
0.854
0.770
0.871
0.946
0.979
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Table 6 Proportional distribution of diagnoses in particular results of MoCA scale. Overall MoCA result 0–19 20–26 27–30
Organically based disorders (N=24)
Disorders due to substance use (N=25)
Psychotic disorders (N=77)
Affective disorders (N=44)
Neurotic disorders (N=28)
Personality disorders (N=24)
67% 29% 4%
4% 84% 12%
25.9% 46.7% 27.2%
6.8% 54.6% 38.6%
0% 57.2% 42.8%
0% 20.8% 79.2%
range 0–19 points, while majority of patients with personality disorders scored in the highest results’ range. Comparisons between particular subgroups in terms of average MoCA scale results suggest that majority of the expected intergroup differences were confirmed. Moreover, the analysis of sensitivity and specificity based on ROC curves indicates that MoCA’s overall results appear to be sufficiently good classifier in distinguishing the patients with organically based disorders from other combined groups, as well as from more specific groups (substance use, psychotic, affective, anxiety and personality disorders). The obtained results confirm some aspects of MoCA’s construct validity in the population of psychiatrically hospitalized patients. They also confirm the research that suggests high sensitivity and rather low specificity [16,17] in diagnosing patients with schizophrenia. They appear to be logically coherent with the results suggesting MoCA’s validity in selecting patients with SMI [19]. The data presented in the article confirming MoCA’s concurrent and construct validity are also coherent with the published research regarding different patients groups [32–35]. Similar to studies on patients with dementia and MCI [16,36,37], the overall MoCA’s result appears to be sufficiently good classifier for selecting patients with organically based disorders diagnosis. The problem of differentiating patients with organically based disorders from patients with long-term course of schizophrenia does not imply any drawbacks of the method because the level of cognitive impairment in both groups can be comparable [38]. This would suggest that the rough data obtained by the psychic health specialists with a quick, screening test may accurately identify the necessity of more accurate neuropsychological and neuroimaging diagnosis in both of these groups. The above-described results have numerous limitations. The most important one is the heterogeneous age structure among different diagnoses. While there were no significant age differences in the mental disorders group (MF10-F19=37.08; MF20-F29=38.65; MF30-F39=44.39; MF40-F48.9=40.59), subjects with organically based disorders and personality disorders would differ greatly in terms of age (MF0-F09=52.9; MF60=28). Another limitation is small number of subjects in different diagnostic subgroups that makes the data lack sufficient reliability. Lastly, the validity study needs to be supported by the analysis of internal structure of the scale. Future studies should focus on the abovementioned research areas.
5. Conclusions The obtained results suggest the following: (1) The results bring new evidence supporting the construct and concurrent validity of MoCA in psychiatrically hospitalized patients. (2) MoCA’s overall result is a satisfactory classifier for selecting patients with organically based disorders from other patients groups. Score lower than 23 points should suggest the possibility of future organically based disorders diagnosis. The risk of type II error should be taken into account. The falsely positive diagnosis of organically based disorders mainly concerns patients with long-term course of schizophrenia in whom the need of further diagnosis is equally important. (3) The abovementioned conclusions suggest high usefulness of MoCA in advisory and general hospital psychiatry.
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The Montreal Cognitive Assessment as a preliminary assessment tool in general psychiatry Validity of MoCA in psychiatric patients J. Gierus, M.A. a,b,⁎, A. Mosiołek, M.D., Ph.D. a,b, T. Koweszko, M.A. a,b, P. Wnukiewicz, M.A. a, O. Kozyra, M.A. a, A. Szulc, M.D., Ph.D. a,b a b
The Prof. Jan Mazurkiewicz Mazovia Specialist Health Centre, Pruszków, Poland Clinic of Psychiatry, Department of Health Sciences, Medical University of Warsaw, Pruszków, Poland
a r t i c l e
i n f o
Article history: Received 17 July 2014 Revised 18 May 2015 Accepted 22 May 2015 Keywords: Montreal Cognitive Assessment (MoCA) Cognitive assessment Psychiatric patients
a b s t r a c t Objective: The aim of the presented research was to obtain the initial data regarding the validity of Montreal Cognitive Assessment (MoCA) in diagnosing cognitive impairment in psychiatrically hospitalized patients. Method: The results in MoCA obtained from 221 patients were analyzed in terms of proportional participation of patients with particular diagnosis in three result ranges. In 67 patients, additional version of the scale was also used. Comparative analysis of average results in particular diagnostic groups (organically based disorders, disorders due to psychoactive substance use, psychotic disorders, neurotic disorders and personality disorders) was also carried out, as well as an analysis of the scale’s accuracy as a diagnostic test in detecting organic disorders. Results: The reliability of the test measured with between tests correlation coefficient rho=0.92 (P=.000). Significant differences between particular diagnoses groups were detected (J–T=13736; P=.000). The cutoff points of 23 turned out to have a satisfactory sensitivity and specificity (0.82 and 0.70, respectively) in diagnosing organically based disorders. The area below the receiver operating characteristic curve (AUC=0.854; P=.000) suggests that MoCA has a satisfactory value as a classifier. Conclusion: The initial data suggest MoCA’s high value in prediction of future diagnosis of organically based disorders. The initial results obtained in particular group of diagnoses support construct validity of the method. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Diagnosing cognitive functions appears to be at least as important for the psychiatric patients functioning as axial symptoms of psychic disorders [1–4]. The occurrence of cognitive disorders depending on their grounds determines recommendation for neurological (organically based disorders) or psychiatric (schizophrenia, affective disorders) rehabilitation. Two out of six symptom levels of schizophrenia understood as mind entropy [5] concern cognitive functioning: procedural sphere (executive functions and motor capacity) and neuropsychological variables (attention, memory and concentration impairment). In clinical practice, the batteries directed at patients with specific diagnoses, such as MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) or TURNS (Treatment Units for Research on Neurocognition and Schizophrenia), are used [6]. However, the use of these methods often requires computer equipment, specialized trainings for the diagnosticians and at least 90–120 min of time [7,8]. Screening methods that take approximately 15–20 min, such as B-CATS (Brief Cognitive Assessment Tool for ⁎ Corresponding author. Clinic of Psychiatry, Department of Health Sciences, Medical University of Warsaw, Pruszków, Poland, Partyzantów 2/4, 05-802 Pruszków, Poland. Tel.: +48-22-758-63-71; fax: +48-22-758-75-70. E-mail address: [email protected] (J. Gierus). http://dx.doi.org/10.1016/j.genhosppsych.2015.05.011 0163-8343/© 2015 Elsevier Inc. All rights reserved.
Schizophrenia), are often meant for patients with a specific diagnosis or, like in case of The Mini-Mental State Examination (MMSE), are designed for the diagnosis of more severe cognitive impairment [8–11]. This is why tools with confirmed diagnostic value in various neurological and psychiatric disorders become useful in screening diagnostics since they enable the diagnostician to quickly build a rough image of patients’ cognitive functioning. One of such tools is the Montreal Cognitive Assessment (MoCA). Majority of research regarding validity of the scale concerns mild cognitive impairment (MCI) and dementia, although its structure suggests very broad scope of possible use. The article concerns chosen aspects of MoCA’s scale validity in psychiatrically hospitalized patients. The MoCA has been designed for screening detection of MCI displaying a more favorable sensitivity and specificity in diagnosis than MMSE [12]. The scale is useful in detecting cognitive disorders with vascular origin, cerebral cancer metastases, brain tumors, Huntington’s disease and Parkinson’s disease [12–15], as well as the course of schizophrenia [16,17] and sleep disorders [18]. Recently, there has been some research published suggesting MoCA’s high diagnostic value in terms of cognitive impairment in patients with severe mental illness (SMI). A total of 89% of patients with SMI obtained less than 26 points, which was accepted as the cutoff point. The specificity for this point was 61%. MoCA turned out to be a better classifier than BACS (Brief Assessment of Cognition in Schizophrenia) [19]. In different studies, cognitive
J. Gierus et al. / General Hospital Psychiatry 37 (2015) 476–480 Table 1 Average MoCA results in different diagnostic groups. Diagnosis
N
M
SD
Organically based disorders Disorders due to psychoactive substance use Psychotic disorders Affective disorders Neurotic disorders Personality disorders
23 25 77 44 28 24
17.78 23.56 22.60 24.39 26.07 27.83
4.562 2.451 5.014 3.418 2.340 2.078
disorders have been confirmed in 81.3% of patients whose MoCA score suggested such disorders [20]. In Poland, there are two versions of MoCA scale: the adaptation of the first English basic version [21] as well as the adaptation of the English version 7.2 [22]. The current article describes the chosen aspects of MoCA’s construct validity in the group of patients hospitalized in a psychiatric hospital. It also deals with the concurrent validity and criterion validity of MoCA scale in detecting patients with organically based diagnosis compared to the rest of patients. 2. Materials and methods 2.1. The source of data A total of 221 patients aged 18–82 years, hospitalized in general psychiatric unit in {blind review}, were examined. A total of 45.2% (N= 100) of the subjects were males, while 54.8% (N= 121) were females. In the analyzed sample, 10.4% (N=23) were patients with organically based disorders, 11.3% (N=25) were patients with disorders due to psychoactive substance use, 34.8% (N=77) were patients with psychotic disorders, 19.9% (N=44) were patients with affective disorders, 12.7% (N=28) were patients with neurotic disorders and 10.9% (N=23) were patients hospitalized for a crisis caused by personality disorders. There were no differences in between the sexes in terms of average results in MoCA scale (Mann–Whitney U=5458.00; P=.210). A total of 67 patients (37 males and 30 females) were additionally examined with an alternative version of MoCA 7.2. The order of the execution of each test by the patients was random. 2.2. Measurement The results of 221 patients of {blind review} in the course of diagnostic process were analyzed, and then after the end of the process, the data were assigned to each diagnostic group based on International Statistical Classification of Diseases, 10th Revision (ICD-10) criteria: (1) organically based disorders, (2) mental and behavioral disorders due to psychoactive substance use, (3) psychotic disorders, (4) affective disorders, (5) neurotic disorders and (6) personality disorders. The organically based disorders were diagnosed based on brain damage or significant atrophy displayed by computed tomography or magnetic resonance imaging, consistent in terms of occurrence and time with psychiatric symptoms, changes in electroencephalogram and/or cognitive disorders diagnosed by MMSE, Trail Making Test A and B, Rey Auditory Verbal Learning Test and Rey-Osterrieth Complex Figure Test. Mental and behavioral disorders due to psychoactive substance use, psychotic, affective and neurotic disorders were diagnosed by clinical interview conducted by a psychiatrist and a psychologist as well as M.I.N.I. International Neuropsychiatric Interview and psychiatric observation. Personality disorders’ diagnosis was based on an interview
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conducted by a psychiatrist and a psychologist, observation and the clinical interview Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders II (SCID-II). The data obtained by SCID-II interview were verified in terms of its coefficiency with ICD-10 criteria. None of the subjects was excluded from the group due to inconsistency of the criteria. All diagnoses were supervised by head of hospital ward. PASW Statistics 18 software was used to analyze the data. 3. Results 3.1. Concurrent validity The concurrent validity of the method was verified by calculating the overall scale results correlation coefficient with results of collateral Polish version of MoCA 7.2 test, which is the adaptation of the English version MoCA 7.2 scale. It was crated with the emphasis put on receiving the highest possible resemblance of tasks to the basic version. The Rho-Spearman correlation coefficient between the two versions of MoCA scale was Rho=0.926 (P=.000). The differences between the two tests turned out to be insignificant confirming the nonparametric test’s value for Wilcoxon-dependent data (Z=−0.523; P= .601). Nonparametric statistics were used because distribution of differences between the first and the second measurement was not normal (Shapiro–Wilk W=0.912, P=.001; kurtosis=3.324). 3.2. The chosen aspects of construct validity for psychiatric diagnoses In the analyzed group, the particular diagnoses groups were specified and the descriptive statistics were calculated among them. If MoCA’s results actually reflect the current knowledge, patients with organically based and brain disorders should score the lowest in the considered groups while patients with schizophrenia should score higher than those with organic disorders yet simultaneously lower than patients with affective, anxiety or personality disorders. Such predictions regarding MoCA’s test results are based on the assumption that cognitive deficits in psychic disorders in particular patients have rarely deep and global character, covering merely several cognitive functions [23–25]. The results can be found in Table 1 below. The significance of intergroup differences was verified by the nonparametric Jonckheere–Terpstra test for several dependent samples. The obtained result for six of the compared groups suggests significant differences between average results in diagnostic groups (Table 2). Since the MoCA results distribution in the examined groups deviated from normal, the post hoc analysis was conducted with the use of Mann–Whitney U test. The results of patients from the organic disorders groups turned out to be the lowest and they significantly differed from average results of other clinical groups. Average results of patients with psychotic disorders, disorders due to psychoactive substance use and affective disorders did not differ from each other. They were, however, significantly higher than the results of patients with organically based disorders and lower than those of patients with neurotic and personality disorders. No differences were found between the average results in MoCA in patients with personality and neurotic disorders (Table 3). 3.3. Sensitivity, specificity and accuracy in detection of organically based disorders MoCA’s overall result validity as a classifier in psychiatric patients group was verified through receiver operating characteristic (ROC) curve: (1) in distinguishing organically based disorders from other
Table 2 Nonparametric statistics for K dependent samples (N=221) in Jonckheere–Terpstra test. Observed J-T statistics
Mean J-T statistics
Standard deviation of J-T statistics
Standard. J-T statistics
Asymptotic significance (two tailed)
13,736.000
9615.500
531.889
7.747
0.000
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Table 3 MoCA results — Differences between individual groups and tests of statistical significance of the differences (Mann–Whitney U test). A
B
Difference in means (A−B)
Mann–Whitney U significance
F00-F09
F10-F19 F20-F29 F30-F39 F40-F49 F60 F00-F09 F20-F29 F30-F39 F40-F49 F60 F00-F09 F10-F19 F30-F39 F40-F49 F60 F00-F09 F10-F19 F20-F29 F40-F49 F60 F00-F09 F10-F19 F20-F29 F30-F39 F60 F00-F09 F10-F19 F20-F29 F30-F39 F40-F49
−5.777⁎ −4.815⁎ −6.604⁎ −8.289⁎ −10.051⁎ 5.777⁎
0.000 0.000 0.000 0.000 0.000 0.000 0.643 0.259 0.001 0.000 0.000 0.643 0.080 0.001 0.000 0.000 0.259 0.080 0.034 0.000 0.000 0.001 0.001 0.034 0.004 0.000 0.000 0.000 0.000 0.004
F10-F19
F20-F29
F30-F39
F40-F49
F60
.963 -.826 −2.511 −4.273⁎ 4.815⁎ -.963 −1.789 −3.474⁎ −5.236⁎ 6.604⁎ .826 1.789 −1.685 −3.447⁎ 8.289⁎ 2.511 3.474⁎ 1.685 −1.762 10.051⁎ 4.273⁎ 5.236⁎ 3.447⁎ 1.762
Table 5 Sensitivity and specificity of particular raw MoCA data. Positive if less than or equal toa 5.00 8.00 10.50 11.50 12.50 13.50 14.50 15.50 16.50 17.50 18.50 19.50 20.50 21.50 22.50 23.50 24.50 25.50 26.50 27.50 28.50 29.50 31.00
Sensitivity
1−Specificity
.000 .000 .087 .087 .130 .174 .217 .304 .435 .522 .522 .696 .739 .783 .826 .826 .957 .957 .957 1.000 1.000 1.000 1.000
.000 .005 .005 .010 .015 .015 .025 .035 .040 .066 .091 .121 .172 .247 .303 .374 .475 .556 .636 .753 .843 .955 1.000
The test result variable(s): MoCA result has at least one tie between the positive actual state group and the negative actual state group. a The smallest cutoff value is the minimum observed test value minus 1, and the largest cutoff value is the maximum observed test value plus 1. All the other cutoff values are the averages of two consecutive ordered observed test values.
F00-F09, organically based disorders; F10-F19, disorders due to psychoactive substance use; F20-F29, psychotic disorders; F30-F39, affective disorders; F40-F49, neurotic disorders; F60, personality disorders.
combined patients groups and (2) in differentiating patients with personality disorders from other combined patients. The groups were chosen based on the expected extreme results compared with other groups. Next, ROC curves in distinguishing organically based disorders from other groups separately (substance use, anxiety and personality disorders) were drawn. The area below the ROC curve (AUC=0.854) indicates an initially satisfactory classifier’s value for the organically based disorders screening test. Moreover, the area below the ROC curve indicates satisfactory diagnostic value of MoCA (AUC=0.839) as a test for selecting patients with personality disorders from other groups (Table 4). The abovementioned data suggest that MoCA’s overall result is the most accurate in distinguishing organically based disorders from anxiety and personality disorders and least accurate in terms of differentiating these from the psychotic disorders. The analysis of possible cutoff points suggests that the raw data lower than 23 points appear to have a satisfactory sensitivity and specificity in distinguishing patients with organically based disorders from the other patients groups (0.82 and 0.70, respectively) (Table 5). After analyzing the observations including wrong diagnoses, it turned out that, out of the 31 false diagnoses, 22 concerns false-positive diagnoses in patients with long course of schizophrenia. The test’s low specificity is likely to be the result of higher value of false-positive diagnoses. In order to illustrate the different diagnosis groups’ distribution, the percentage data were grouped in point ranges based on the average and standard deviation.
Table 6 shows the proportional participation of patients with particular diagnoses in three result ranges (0–19; 20–26; 27–30). The results in particular groups distribute in a different and specific way, and at the same time, such configuration suggests that many patients with psychotic disorders score similarly to patients with organically based disorders. Very common score in all of the groups is the result between 20 and 26 points. 4. Discussion If we look at particular groups of disorders, one might expect that patients with organic disorders achieve the lowest results among all of the groups [26,27]. In this case, the largest group of patients scored below 19 and merely 4% scored 27 points and higher. In patients with disorders due to psychoactive substance use, one might expect a diverse lowering of cognitive functions, merely reaching the global or profound level [28,29], and this also suggests proportional distribution of patients in the results’ ranges — 84% of the subjects obtained results of 20–26 points. Patients with psychotic disorders might score differently in terms of cognitive functions and this fact might depend on the time and the course of the illness [19,25]. In this case, the largest group includes patients with scores between 20 and 26 points and two slightly smaller groups distribute almost equally in the remaining ranges. This might be the reflection of the fact that there were patients with different time span of the illness and the level of functioning among the subjects also differed. The majority of the subjects with affective disorders scored between 20 and 26 points and the result might suggest mild lowering of cognitive functions that may also appear consistent with the literature and existing studies [30,31]. In patients with neurotic and personality disorders, the most favorable results were expected and this expectation was confirmed: none of the patients in these groups scored in the
Table 4 Area under ROC curve for differentiating organically based disorders from other groups of diagnoses. Organically based disorders vs. substance use disorders
Organically based disorders vs. psychotic disorders
Organically based disorders vs. mood disorders
Organically based disorders vs. anxiety disorders
Organically based disorders vs. personality disorders
0.854
0.770
0.871
0.946
0.979
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Table 6 Proportional distribution of diagnoses in particular results of MoCA scale. Overall MoCA result 0–19 20–26 27–30
Organically based disorders (N=24)
Disorders due to substance use (N=25)
Psychotic disorders (N=77)
Affective disorders (N=44)
Neurotic disorders (N=28)
Personality disorders (N=24)
67% 29% 4%
4% 84% 12%
25.9% 46.7% 27.2%
6.8% 54.6% 38.6%
0% 57.2% 42.8%
0% 20.8% 79.2%
range 0–19 points, while majority of patients with personality disorders scored in the highest results’ range. Comparisons between particular subgroups in terms of average MoCA scale results suggest that majority of the expected intergroup differences were confirmed. Moreover, the analysis of sensitivity and specificity based on ROC curves indicates that MoCA’s overall results appear to be sufficiently good classifier in distinguishing the patients with organically based disorders from other combined groups, as well as from more specific groups (substance use, psychotic, affective, anxiety and personality disorders). The obtained results confirm some aspects of MoCA’s construct validity in the population of psychiatrically hospitalized patients. They also confirm the research that suggests high sensitivity and rather low specificity [16,17] in diagnosing patients with schizophrenia. They appear to be logically coherent with the results suggesting MoCA’s validity in selecting patients with SMI [19]. The data presented in the article confirming MoCA’s concurrent and construct validity are also coherent with the published research regarding different patients groups [32–35]. Similar to studies on patients with dementia and MCI [16,36,37], the overall MoCA’s result appears to be sufficiently good classifier for selecting patients with organically based disorders diagnosis. The problem of differentiating patients with organically based disorders from patients with long-term course of schizophrenia does not imply any drawbacks of the method because the level of cognitive impairment in both groups can be comparable [38]. This would suggest that the rough data obtained by the psychic health specialists with a quick, screening test may accurately identify the necessity of more accurate neuropsychological and neuroimaging diagnosis in both of these groups. The above-described results have numerous limitations. The most important one is the heterogeneous age structure among different diagnoses. While there were no significant age differences in the mental disorders group (MF10-F19=37.08; MF20-F29=38.65; MF30-F39=44.39; MF40-F48.9=40.59), subjects with organically based disorders and personality disorders would differ greatly in terms of age (MF0-F09=52.9; MF60=28). Another limitation is small number of subjects in different diagnostic subgroups that makes the data lack sufficient reliability. Lastly, the validity study needs to be supported by the analysis of internal structure of the scale. Future studies should focus on the abovementioned research areas.
5. Conclusions The obtained results suggest the following: (1) The results bring new evidence supporting the construct and concurrent validity of MoCA in psychiatrically hospitalized patients. (2) MoCA’s overall result is a satisfactory classifier for selecting patients with organically based disorders from other patients groups. Score lower than 23 points should suggest the possibility of future organically based disorders diagnosis. The risk of type II error should be taken into account. The falsely positive diagnosis of organically based disorders mainly concerns patients with long-term course of schizophrenia in whom the need of further diagnosis is equally important. (3) The abovementioned conclusions suggest high usefulness of MoCA in advisory and general hospital psychiatry.
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