If the measurement of dementia varies by race and ethnicity, we will inaccurately label exposures as risk factors. To clearly delineate exposure risks in a population, we also need to accurately determine who has, and has not, the outcome of interest, in this case, dementia. Underlying the consideration of exposure is the consideration of outcome. Therefore, because exposures vary by race and ethnicity, and because such exposures are predictive, it is imperative to consider race and ethnicity when interpreting performance on cognitive tests. Performance on cognitive testing is, in part, affected by a range of exposures throughout the lifecourse 23 these exposures are unequally distributed by race and ethnicity and their presence can explain differences in the burden of dementia as well as performance on cognitive tests. However, these studies did not examine differences by race or ethnicity. 22 Another study among over 400 individuals evaluated in a clinical research setting (76.7% Caucasian), looking to create an abbreviated MoCA with the three items with the largest effect sizes, found that serial 7s and delayed recall were the best items for distinguishing between normal aging and MCI while the serial 7s, delayed recall, and orientation items were the best at discriminating between MCI and AD. 22 They found that the clock drawing, serial 7s, orientation-place, delayed recall, abstraction, rhinoceros naming, trails, and fluency subtests discriminated between the two groups.

21 Additionally, Roalf and colleagues examined the ability of MoCA subtests and items to discriminate between healthy controls and affected individuals (MCI, AD, Parkinson’s disease, or Parkinson’s disease dementia) in a sample of almost 2000 community dwelling individuals (>80% Caucasian) with the goal of creating a short version of the examination. 20 A study that did examine MoCA subtests and items individually among Brazilians, aged 60 and over and with over four years of formal education, found that word repetition, inverse digits, serial 7, phrases, verbal fluency, abstraction, and word recall discriminated between MCI and normal aging and that the clock drawing, rhinoceros naming, delayed recall of five words, and orientation discriminated between MCI and AD. The MoCA is an important tool for detection of MCI and dementia however, the psychometric properties of its subtests and items have not been widely studied. 11 However, the utility of this cutoff has been widely questioned, 14, 15 especially for use in minority populations. 11 The validation study of the MoCA found that with a cutoff of 26 or less, the MoCA had a much higher sensitivity compared to the MMSE (90% vs 18%, respectively). 11– 13 The MoCA is one page, 30 point assessment, covering eight cognitive domains, with a suggested cutoff of 26 for cognitive impairment. The Montreal Cognitive Assessment (MoCA) is widely accepted to be a better test for detecting MCI than the Mini-Mental State Examination (MMSE), one of the most frequently used neuropsychologic tests. 7, 9, 10 However, we must consider if these are true differences in dementia incidence and distribution of risk factors or are the result of measurement bias in these populations when examining rates of cognitive impairment as well as its associated risk factors. 7 This disparity in dementia burden is potentially attributed to a higher burden of risk factors, especially socioeconomic risk factors, for dementia among minority populations. 7 Hispanics also have a high burden of AD, with one and a half times the risk of developing late onset AD compared to their White counterparts. 7, 8 African Americans have double the risk of developing late onset Alzheimer’s disease (AD), the most common type of dementia, compared to their White counterparts. Racial and ethnic minority groups have disproportionally high rates of dementia. 4 Diagnosis of MCI is difficult to ascertain, 3, 5 however, early detection is crucial to prevent further impairment, manage patients comorbid conditions, and allow patients to express their directives before impairment becomes too severe. 3 Most people with MCI do not progress to develop dementia a review of 41 studies found that less than half of individuals with MCI develop dementia. 2 Mild cognitive impairment (MCI) is defined as cognitive impairment that is greater than expected for one’s age but is not as severe as dementia. 1 As the population ages, the number of older adults at risk for developing dementia will increase. Dementia, a broad category of neurodegenerative disorders, affects approximately 8.8% of the population aged 65 and older.

Moca scoring cutoffs