The Montreal Cognitive Assessment After Omission of Hearing-Dependent Subtests: Psychometrics and Clinical Recommendations

Abstract

Objectives: Hearing loss (HL) is the third most common chronic health condition in older adults, yet it is often undiagnosed and/or untreated. Given the association between HL and cognitive impairment, it is expected that many people undergoing cognitive screening may have HL. The Montreal Cognitive Assessment (MoCA) is a brief screening test that assesses a wide range of cognitive functions sensitive to Alzheimer's disease (AD) and mild cognitive impairment (MCI). Although MoCA items were carefully designed to be sensitive to deficits in MCI, they were not designed to take sensory declines into account. In the current investigation, we examined the MoCA's psychometric properties following omission of subtests primarily dependent on hearing status (memory, digit span, attention to letters, and sentence repetition).

Design: Cross-sectional analytic design (retrospective analysis).

Setting: We used the original MoCA validation study data.⁴ PARTICIPANTS: Groups consisted of healthy controls (N = 90), subjects with MCI (N = 94), and subjects with mild AD (N = 93).

Measurements: We assessed sensitivity and specificity using absolute and proportional cutoff score adjustments. We developed receiver operating characteristics curves to determine the best cutoff values for both MCI and AD patients using different combinations of auditory subtest omissions.

Results: Compared with the original MoCA (MCI sensitivity = 90%; specificity = 87%), MCI sensitivity was substantially reduced (absolute scoring = 43%; proportional scoring = 56%) when all auditory subtests were omitted, with the biggest contribution to the reduction coming from the delayed recall subtest. Excluding three subtests and maintaining the delayed recall had no effect on MCI sensitivity but reduced specificity (sensitivity = 94%, specificity: 71% using proportional scoring). AD sensitivity, in contrast, was not strongly influenced by our manipulation and remained relatively high through all three subtest omission combinations.

Conclusion: The current study highlights the contribution of hearing-dependent subtests on the sensitivity and specificity of the MoCA. Clinical recommendations related to these findings are discussed. J Am Geriatr Soc 67:1689-1694, 2019.

Keywords: Montreal Cognitive Assessment (MoCA); cognitive screening; delayed recall; hearing loss; psychometrics.