Examining the Effects of Formal Education Level on the Montreal Cognitive Assessment

Renee S. White, Justin M. Barber, Jordan P. Harp, Gregory A. Jicha

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Background: Brief, global assessments such as the Montreal Cognitive Assessment (MoCA) are widely used in primary care for assessing cognition in older adults. Like other neuropsychological instruments, lower formal education can influence MoCA interpretation. Methods: Data from 2 large studies of cognitive aging were used—Alzheimer’s Disease Neuroimaging Initiative (ADNI) and National Alzheimer’s Coordinating Center (NACC). Both use comprehensive examinations to determine cognitive status and have brain amyloid status for many participants. Mixed models were used to account for random variation due to data source. Results: Cognitively intact participants with lower education (≤12 years) were more likely than those with higher education (>12 years) to be classified as potentially impaired using the MoCA cutoff of <26 (P < .01). Backwards selection revealed 4 MoCA items significantly associated with education (cube copy, serial subtraction, phonemic fluency, abstraction). Subtracting these items scores yielded an alternative MoCA score with a maximum of 24 and a cutoff of ≤19 for classifying participants with mild cognitive impairment. Using the alternative MoCA score and cutoff, among cognitively intact participants, both education groups were similarly likely to be classified as potentially impaired (P > .67). Conclusions: The alternative MoCA score neutralized the effects of formal education. Although further research is needed, this alternative score offers a simple procedure for interpreting MoCAs administered to older adults with ≤12 years education. These educational effects also highlight that the MoCA is part of the assessment process—not a singular diagnostic test—and a comprehensive workup is necessary to accurately diagnose cognitive impairments.

Original languageEnglish
Pages (from-to)1043-1057
Number of pages15
JournalJournal of the American Board of Family Medicine
Issue number6
StatePublished - Nov 2022

Bibliographical note

Publisher Copyright:
© 2022 American Board of Family Medicine. All rights reserved.


  • Clinical Medicine
  • Cognition
  • Cognitive Aging
  • Geriatrics
  • Montreal Cognitive Assessment
  • Neuropsychology
  • Psychometrics

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Family Practice


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