BRIEF REPORTS
Validation of the Chinese Version of Montreal Cognitive
Assessment Basic for Screening Mild Cognitive Impairment
Ke-Liang Chen, MD,* Yan Xu, MD,* Ai-Qun Chu, MD, Ding Ding, PhD,* Xiao-Niu Liang,
MPH,* Ziad S. Nasreddine, MD, Qiang Dong, MD, PhD,* Zhen Hong, MD,* Qian-Hua Zhao,
MD, PhD,* and Qi-Hao Guo, MD, PhD*
OBJECTIVES: To evaluate the effectiveness of the Chi-
nese version of the Montreal Cognitive Assessment Basic
(MoCA-BC) as a screening tool for detecting mild cogni-
tive impairment (MCI) in Chinese elderly adults.
DESIGN: Cross-sectional.
SETTING: Huashan Hospital, Shanghai, China.
PARTICIPANTS: Individuals with MCI (n = 264) and
mild Alzheimers disease (AD) (n = 160) were recruited
from the Memory Clinic, Huashan Hospital; cognitively
normal controls were recruited from Jinshan Community,
Shanghai, China (n = 280).
MEASUREMENTS: MoCA-BC scores.
RESULTS: The MoCA-BC had good criterion-related
validity (Pearson correlation coefficient MoCA-BC vs
MMSE = 0.787) and reliable internal consistency (Cron-
bach alpha = 0.807). The optimal cutoff scores for MCI
screening were 19 for individuals with no more than
6 years of education, 22 for individuals with 7 to 12 years
of education, and 24 for individuals with more than
12 years of education. The MoCA-BC was superior to the
MMSE for detecting MCI, with optimal sensitivity and
specificity across all education groups using the above cut-
off scores.
CONCLUSION: The MoCA-BC is a reliable cognitive
screening test across all education levels in Chinese elderly
adults, with high acceptance and good reliability. J Am
Geriatr Soc 2016.
Key words: Montreal Cognitive Assessment; Mini-Mental
State Examination; mild cognitive impairment; Alzheimers
disease
From the *Department of Neurology, Institute of Neurology, Huashan
Hospital, Shanghai Medical College, Fudan University; Community
Health Service Center of Jinshan Shihua, Shanghai, China; and MoCA
Clinic and Institute, Greenfield Park, Quebec, Canada.
Address correspondence to Qi-Hao Guo, Department of Neurology and
Institute of Neurology, Huashan Hospital, Shanghai Medical College,
Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China.
E-mail: dr.guoqihao@126.com
DOI: 10.1111/jgs.14530
JAGS 2016
2016, Copyright the Authors
Journal compilation 2016, The American Geriatrics Society
T he Montreal Cognitive Assessment (MoCA) was
designed as a quick evaluation scale to screen for
mild cognitive impairment (MCI)13 that has been vali-
dated in a group of highly educated elderly adults (aver-
age education 13 years) for differentiating individuals
with MCI from healthy elderly adults,2 but several
MoCA subtests incorporate tasks that may be influenced
by formal education or literacy levels, such as the
Trail-Making Test (TMT), cube copy, and naming low-
familiarity animals.4,5 This may limit the use of the test
in individuals with low education or who are illiterate,
because low scores may reflect lack of education more
than cognitive impairment.6,7 In addition, there are vari-
ous Chinese versions of the MoCA, including Beijing,
Changsha, Cantonese, Hong Kong, Taiwan, Singapore,
and Mandarin version (www.mocatest.org). There are
subtle differences between these versions in the stimuli
and materials used in the TMT, verbal fluency, delayed
recall, abstraction, and naming tests. Adjustment for level
of education and cutoff scores for MCI were also differ-
ent in each of these versions.811 In clinical practice,
these differences between the various Chinese MoCA ver-
sions may increase the possibility of false positives and
thus lower the validity of Chinese versions of the
MoCA.12 A unified Chinese version of quick assessment
to screen for MCI is desirable.
A revised MoCA test, the MoCA basic (MoCA-B),
was developed to screen for MCI in illiterate individu-
als and those with little education.13 A Thai-language
version of the MoCA-B showed excellent validity and
accuracy in screening less-educated Thai elderly adults
with MCI. Given that China has a large proportion of
less-educated elderly adults, the MoCA-B may be more
valid for screening MCI in Chinese elderly adults than
the previous version. The Chinese version of the
MoCA-B (MOCA-BC) has been translated from the
original English version. The goal of the present study
was to examine the sensitivity and specificity of the
MoCA-BC as a screening tool for MCI in Chinese
older adults and to determine the corresponding opti-
mal cutoff points.
0002-8614/16/$15.00
2 CHEN ET AL. 2016 JAGS

Hospital. Each examiner had undergone adequate training

METHODS
Chinese Version of MoCA-B
The MoCA-BC was translated from the original English ver-
sion with subtle linguistic and cultural modifications. The
original author (ZSN) reviewed and approved the back-
translated MoCA-B version. The MoCA-BC assesses nine
cognitive domains (executive function, language, orienta-
tion, calculation, conceptual thinking, memory, visuoper-
ception, attention, and concentration) and is freely available
for clinical use (www.mocatest.org, visit Basic section).
for applying the whole set of assessments before the study.
Examiners did not know subjects diagnoses, and each
examiner assessed only one subject at a time.
Other neuropsychological tests of global cognition,
language, attention, executive function, and visuospatial
ability were administered: MMSE, Auditory Verbal Learn-
ing Test, Rey-Osterrieth Complex Figure Test, Boston
Naming Test, Animal Verbal Fluency Test, TMT, Stroop
Color Word Test, Symbol Digit Modalities Test, activity
of daily living scale, Modified Hachinski Ischemic Scale,19
CDR, and Hamilton Depression Rating Scale.21

Participants
Statistical Analyses
Seven hundred four individuals were recruited: 280 cogni-
The effect of age and education level on MoCA-BC perfor-
tively normal controls, 264 individuals with MCI, and 160
mance was examined using Pearson correlation analysis
individuals with mild Alzheimer disease (AD).
and multiple linear regression models. Chi-square analysis
All participants with MCI and AD were recruited
and one-way analysis of variance were used to assess pos-
from the Memory Clinic, Huashan Hospital, from October
sible group differences between the three groups (MCI,
2015 to February 2016. Controls were recruited from Jin-
AD, controls) in demographic characteristics and cognitive
shan Community, Shanghai, China. All subjects underwent
test performance. Post hoc pairwise between-group com-
a complete neurological and neuropsychological assess-
parisons were assessed using the least significant difference
ment, brain imaging, and other necessary laboratory tests.
test. Interrater reliability was assessed using intraclass cor-
Written consent was obtained from subjects or their legally
relation coefficients in a subsample of 30 participants (18
authorized caregivers. The ethics committee of Huashan
MCI and AD, 12 controls), 33.5  6.8 days apart on
Hospital approved this study.
average. Cronbach alpha was computed to measure the
Inclusion criteria for all participants were age 50 to
internal consistency of the MoCA-BC, and Pearson corre-
85, normal or nearly normal eyesight and hearing, no
lation coefficients (r) between the MoCA-BC and the
(other) serious neuropsychiatric or other disease that
MMSE were calculated to index criterion-related validity.
would affect study performance, and willingness and abil-
Receiver operating characteristic (ROC) curves were used
ity to complete all neuropsychological assessments.
to determine the ability of MoCA-BC to discriminate
MCI diagnosis was made according to previously
between participants with normal cognition, MCI, and
established guidelines:14 cognitive impairment verified by
AD. The area under the ROC curve (AUC) was used to
proxy or caregiver; normal activities of daily living or
compare the diagnostic performance of the MoCA-BC and
slight impairment in instrumental activities of daily liv-
the MMSE. The level of significance was set at a = .05.
ing;15 objective cognitive impairment (Mini-Mental State
All analyses were conducted using SPSS version 19.0 (IBM
Examination (MMSE) score cutoff16 and Clinical Demen-
Corp., Armonk, NY).
tia Rating (CDR) score of 0.5,17 or performance on a set
of comprehensive neuropsychological tests 1.5 standard
deviations or more below the normative mean (Table S1)); RESULTS
and no dementia. Individuals with AD were required to
meet the National Institute of Aging (NIA) and Alzheimers Demographic Information and Global Cognitive
Association (AA) diagnostic criteria for AD.18 Briefly, indi- Assessment (MoCA-BC and MMSE) Results
viduals with AD were characterized by insidious onset of
The demographic characteristics of each group are summa-
symptoms, clear-cut history of cognitive decline by report
rized in Table S2. Correlation between MoCA-BC score
or observation, and the initial and most-prominent cogni-
and demographic characteristics were carried out in the
tive deficits being (typically) amnestic or nonamnestic (in-
control group. Correlation analysis revealed that MoCA-
cluding language, visuospatial or executive deficits).
BC scores were weakly associate with age (r = 0.139,
Except for the common inclusion criteria, controls
P = .02) and more strongly associated with education
were required to have no cognitive impairment, verified
(r = 0.461, P < .001). Multiple linear regression analysis
according to no significant impairment in cognitive func-
also demonstrated a positive correlation between education
tion or activities of daily living, no memory complaints or
level and MoCA-BC total score independent of age and
memory impairments reported by informants, MMSE
clinical diagnosis (Table S3). To reduce educational bias,
score at or above the cutoff,16 a Modified Hachinski
subjects were divided into three educational subgroups
Ischemic Scale score of 4 or less,19 a CDR score of 0,17
according to years of formal education: low (6 years),
and a Hamilton Depression Rating Scale (17-item scale)
middle (712 years), high (>12 years). The demographic
score of 12 or less in the past 2 weeks.20
characteristics and total MMSE and MoCA-BC scores of
the three educational subgroups were shown in Table 1. A
Neuropsychological Assessment
second multiple regression analysis conducted in each of
Five examiners conducted all neuropsychological assess- the subgroups showed that education level did not affect
ments in the neuropsychological laboratory of Huashan MoCA-BC total scores within each subgroup (Table S4).
JAGS 2016 VALIDATION OF CHINESE VERSION OF MONTREAL COGNITIVE ASSESSMENT BASIC 3

Total MMSE and the MoCA-BC scores of each

P-Value
Table 1. Demographic Characteristics and Montreal Cognitive Assessment Basic Chinese Version (MoCA-BC) and Mini-Mental State Examination (MMSE)

<.001
<.001

<.001

<.001
.01
diagnosis group were ranked in the order of con-
trols >MCI>AD (Table 1) in the whole study sample and
in the three educational subgroups.

73.2  7.6c
15.3  1.1c

21.2  3.9c

12.5  3.7c
(n = 40)
AD

19
21
Psychometric Properties of MoCA-BC
High Education

The intraclass correlation coefficient for interrater reliabil-

ity was 0.96 (P < .001). The Cronbach alpha was 0.807,
14.1  2.0b

26.8  2.1b

22.2  2.2b
71.1  8.0 indicating a high level of internal consistency. The correla-
(n = 88)

tion coefficient between MoCA-BC and MMSE was 0.787

MCI

45
43
(P < .001), indicating good criterion-related validity.
Only one control subject (0.4%) obtained the maxi-
mum total MoCA-BC score. In the MCI and AD groups,
65.6  8.1a

28.4  1.3a

25.7  2.0a
no subject obtained a total MoCA-BC score of 0. Thus, no
13.8  1.9
(n = 110)
Control

obvious ceiling and floor effects were found.

76a
34

ROC Analysis of the MoCA-BC for Discriminating

Between Controls and Individuals with MCI and AD
P-Value

<.001
<.001

.001

<.001

<.001

The optimal MoCA-BC cutoff scores for discriminating

individuals with MCI from controls were determined in
each educational subgroup (Table 2). The most appropri-
68.3  8.8c
10.1  1.8c

19.3  3.2c

11.0  3.3c

ate MoCA-BC cutoffs were 19 in the low education group

(n = 82)
AD

41c

(6 years) (sensitivity 87.9%, specificity 81.0%, AUC

41
Middle Education

0.896); 22 in the middle education group (712 years)

(sensitivity 92.9%, specificity 91.2%, AUC 0.949); and 24
in the high education group (>12 years) (sensitivity
26.1  1.9b

18.7  2.5b
69.1  8.5
10.2  1.6
(n = 113)

89.9%, specificity 81.5%, AUC 0.916). Using these cutoff

MCI

43
70

scores, the MoCA-BC showed excellent sensitivity, speci-

ficity, and AUC in all education groups. In comparison,
the MMSE (cutoffs 26, 27, and 28, respectively, in each
educational subgroup) had excellent sensitivity (86.2%,
63.4  6.8a
9.4  1.0a

27.7  1.8a

24.2  2.4a
(n = 112)
Control

78.6%, and 76.4%, respectively) but poor specificity

85a
27

(60.3%, 52.2%, and 53.4%, respectively) and smaller

AUCs (0.797, 0.736, and 0.721, respectively) than the
MoCA-BC, indicating that the MoCA-BC had better abil-
AD = Alzheimers disease; MCI = mild cognitive impairment; SD = standard deviation.

ity than MMSE to detect MCI (Figure 1AC).

P-Value

<.001

<.001

In the ROC analyses for differentiating MCI from

.95
.01

.53

AD, the MoCA-BC had a smaller AUC than the MMSE in

the low education group, a similar AUC in the middle edu-
cation group, and a larger AUC in the high education
3.7  2.5c

18.4  3.2c

10.9  3.7c
67.9  9.4
(n = 38)

group (Table S5).

AD

29
9
Low Education

DISCUSSION
The goal of the present study was to investigate the relia-
24.6  2.6b

16.0  3.2b
Scores According to Level of Education

68.5  8.5
3.3  2.4
(n = 63)

bility and validity of the MoCA-BC in screening for MCI.

MCI

P < .05: aNC vs MCI, bMCI vs AD, cNC vs AD.

19
44

The study verified that the MoCA-BC has high testretest

reliability, good internal consistency, and good content
validity, demonstrated by high correlation between
MoCA-BC and MMSE total scores.
4.8  1.7a

27.2  1.7a

22.0  3.6a
68.2  9.1
(n = 58)
Control

Education level has been found to affect MMSE and

20
38

MoCA scores.2,2225 Because education level has been con-

sidered to be the strongest noncognitive factor influencing
performance on the MMSE and MoCA, the optimal cutoff
score, mean  SD

points of Chinese versions of the MMSE and MoCA for

MMSE total score,
Age, mean  SD
Education, years,

screening for MCI or AD were developed based on educa-

MoCA-BC total
Factor

tion level.8,25,26 A similar educational effect was observed

mean  SD

mean  SD

in the original MoCA-B study13 and the present study.

Female

Therefore, in the present study, the best screening cutoff

Male
Sex

scores in three educational groups were determined. For

4 CHEN ET AL. 2016 JAGS

in all education groups, indicating that it was valid not

Table 2. Receiver Operating Characteristic Curves for
only in illiterate and less-educated individuals, but also the
Montreal Cognitive Assessment Basic Chinese Version
(MoCA-BC) and Mini-Mental State Examination most-educated individuals.
(MMSE) to Differentiate Individuals with Mild Cogni- The optimal cutoff scores of MoCA-BC for screening
tive Impairment from Cognitively Normal Controls MCI in the present study were lower than found in the
MoCA-B Thai version.13 This may be for several reasons.
Education Area Under Cutoff Sensitivity Specificity First, the method of diagnosing MCI in the two studies
Level (Years) the Curve Score % was different. In the MoCA-B Thai version study, the MCI
Low (6)
diagnosis was mainly based on the CDR, whereas in the
MoCA-BC 0.896 19 87.9 81.0 present study, it was diagnosed based on comprehensive
MMSE 0.797 26 86.2 60.3 neuropsychological tests. A recent study showed that a
Middle (712) higher percentage of MCI was identified using the CDR
MoCA-BC 0.949 22 92.9 91.2 than comprehensive neuropsychological tests, but a higher
MMSE 0.736 27 78.6 52.2 percentage of individuals with MCI identified using
High (> 12) comprehensive neuropsychological tests progressed to
MoCA-BC 0.916 24 89.8 90.9
dementia, suggesting that poor performance on neuropsy-
MMSE 0.721 28 76.4 53.4
chological tests was a better indicator of future progression
to dementia than the CDR.27 In a previous long-term fol-
screening for MCI, a MoCA-BC cutoff total score of 19 low-up study, the conversion rate from MCI to dementia
was proposed for individuals with 6 or fewer years of edu- identified using neuropsychological tests was similar to
cation, 22 for those with with 7 to 12 years, and 24 for that found in the current study.28,29 Second, regional dif-
those with more than 12 years. With these cutoff points, ferences may influence some MoCA-B subtests, such as
the MoCA-BC effectively detected 90.9% of MCI, whereas fruit fluency. For example, in the present study, controls
the MMSE detected only 75%. The MoCA-BC has been produced an average of only approximately 11 fruit names
found to have high sensitivity and specificity in screening in the fluency test, and 72.0% could not get full points
for MCI, consistent with the MoCA-B Thai version.13 The probably because there were more types of fruit in Thai-
large AUC of the MoCA-BC for detecting MCI was found land than in the Shanghai area.

Figure 1. Receiver operating characteristic curve analysis of Mini-Mental State Examination (MMSE) and Montreal Cognitive
Assessment Basic Chinese Version (MoCA-BC) according to education level: (A) low (6 years), (B) middle (712 years),
(C) high (>12 years).
JAGS 2016 VALIDATION OF CHINESE VERSION OF MONTREAL COGNITIVE ASSESSMENT BASIC
Several limitations of this study should be considered
when comprehending and using its results. The research
data were based mainly on urban residents, and data from
rural elderly population and ethnic minority groups were
lacking. In addition, the study was conducted only in
Shanghai. Because there is much geographic and cultural
variability across China, specific regional characteristics
may influence the performance of local residents on these
neuropsychological tests. For example, the word church
used in the delayed recall of MoCA was directly translated
in the Beijing version, whereas it was replaced by temple
in the Cantonese version, because the translator of the
Cantonese version thought that temple was more famil-
iar than church to Chinese older adults.9 These different
words affected the difficulty of delayed recall, which might
affect the validity and reliability of these versions of
MoCA.12 The words used in delayed recall of the MoCA-
B were translated based on Chinese culture, all of which
were familiar to Chinese elderly adults in the south and
north of China. Duture studies should recruit participants
from more-diverse regions of the country.
In conclusion, the present study demonstrated that the
MoCA-BC was a reliable, valid cognitive tool to screen for
MCI in a Chinese elderly population with different educa-
tion levels. The optimal cutoff scores for MCI detection
were 19 for individuals with 6 or fewer years of education,
22 for those with 7 to 12 years of education, and 24 for
those with more than 12 years of education. The MoCA-
BC was found to be more sensitive and accurate in screen-
ing for MCI than the MMSE.
ACKNOWLEDGMENTS
Conflict of Interest: None.
This work was supported by grants from the National
Natural Science Foundation of China to Qi-Hao Guo
(81171019) and the National Basic Research Development
Program of China to Yu-Ru Ye (2013CB530900).
Dr. Ziad Nasreddine is the copyright owner of the
MoCA test. Dr. Guo obtained permission to translate the
MoCA-B from Dr. Nasreddine.
Author Contributions: Guo, Zhao, Dong, Hong,
Nasreddine: concept and design. Chen, Xu, Chu, Liang,
Zhao: data collection. Chen, Ding, Liang, Guo: statistical
analyses. Chen: drafting of manuscript. Guo, Zhao,
Nasreddine: critical revision and finalizing of manuscript.
Sponsors Role: The sponsor had no role in the design,
methods, subject recruitment, data collections, analyses
and preparation of paper.
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6 CHEN ET AL.
SUPPORTING INFORMATION
Additional Supporting Information may be found in the
online version of this article:
Table S1. Description of Neuropsychological Test
Impairment at the 1.5 Standard Deviation Level for Mild
Cognitive Impairment Diagnosis According to Age
Table S2. Demographic Characteristics and Montreal
Cognitive Assessment Basic Chinese Version (MoCA-BC)
and Mini-Mental State Examination (MMSE) Scores
Table S3. Effect of Age, Sex, Education, and Diagnos-
tic Group on Montreal Cognitive Assessment Basic Chi-
nese Version Score (Multivariate Linear Regression)
2016 JAGS
Table S4. Effect of Age, Sex, Education, and Diagnos-
tic Group on Montreal Cognitive Assessment Basic Chi-
nese Version Total Score According to Education
(Multivariate Linear Regression)
Table S5. Receiver Operating Characteristic (ROC)
Curves of the Montreal Cognitive Assessment Basic Chi-
nese Version (MoCA-BC) and Mini-Mental State Examina-
tion (MMSE) for Differentiating Mild Cognitive
Impairment from Alzheimers Disease
Please note: Wiley-Blackwell is not responsible for the
content, accuracy, errors, or functionality of any support-
ing materials supplied by the authors. Any queries (other
than missing material) should be directed to the corre-
sponding author for the article.