What is the Montreal Cognitive Assessment exam?

President Donald Trump has boasted in several recent television appearances about his performance on a screening test intended to assess mild cognitive impairment or early dementia.

It’s unclear if Trump, 74, has taken the test again, but in 2018 he was given the Montreal Cognitive Assessment (MoCA) under Dr. Ronny Jackson, the former White House physician, and at the time had scored a perfect 30 out of 30.

The MoCA test was created by Canadian neurologist Dr. Ziad Nasreddine. The test is 30 questions and designed to take 10 minutes. Questions include drawing a clock, copying a picture of a cube and identifying pictures of animals.

“I created the test in 1996 as a screening examination where we ask the patient several questions,” Nasreddine told NBC News. “Each question is accessing a different part of the brain in terms of cognition.”

It’s a test only given by doctors and not meant for the general public.

“It has to be interpreted by a physician who has expertise in cognitive disorders and cognition,” Nasreddine said.

A score of greater than 26 is considered normal while 18-25 is considered mild cognitive impairment, 10-17 is considered moderate cognitive impairment. A score less than 10 is considered severe cognitive impairment.

Sections of the Montreal cognitive test.Ziad Nasreddine

Trump recently brought up his performance on the test as a challenge to Joe Biden, 77, the presumptive 2020 Democratic presidential nominee. On Wednesday, after a press briefing, Trump spoke to Fox News contributor Dr. Marc Siegel, during which he described the memory portion of the test.

“It’s like you’ll go: Person, woman, man, camera, TV. So they say, ‘Could you repeat that?’ So I said, ‘Yeah. So it’s person, woman, man, camera, TV.’ ‘Okay, that’s very good. If you get it in order, you get extra points.’”

In an interview with Fox News’ Chris Wallace on Sunday, Trump said that the exam gets progressively more difficult.

“Yes, the first few questions are easy, but I’ll bet you couldn’t even answer the last five questions. I’ll bet you couldn’t, they get very hard, the last five questions,” he told Wallace.

Some of the last five questions that Trump was referring to include naming the time and place that you are in, as well as repeating a series of words that you were asked to remember earlier in the test.

Dr. Lawrence Honig, a neurologist and one of the directors of the Alzheimer’s Disease Research Center at Columbia University, said while the test is a pretty good indicator, it’s not perfect. He has seen patients with dementia score greater than 26 and he has seen patients without dementia score below 26.

This is because there are often confounding factors such as the level of education and whether the test is being given in the person’s native language. A person with a a high school education in the United States should be able to get 26 to 30, Honig said.

What does scoring 30 out of 30 mean?

“If you’re looking for Alzheimer’s, then you’d be reassured to say that there’s no signs of that disease,” Nasreddine said, referring to a perfect score on the test.

The Montreal test is not a routine screening test in the same way a colonoscopy or a mammogram are, Honig said.

“There’s no broad consensus that we should be giving MoCA’s to people as part of their wellness examination or general annual physical,” he said.

Symptoms that would prompt giving someone the exam include:

  • patients repeating themselves
  • losing car keys frequently
  • forgetting recent events
  • multiple instances of forgetting conversations

Nasreddine also cautions that this test is not meant to be an IQ test and is not used as a measure of somebody’s intelligence.

“There are no studies showing that this test is correlated to IQ tests,” he said. “The purpose of it was not to determine persons who have a low IQ level. So we cannot say that this test reflects somebody’s IQ.”