International Journal of Neuroscience, 2016; 126(5): 442–447

Copyright © 2015 Taylor and Francis

ISSN: 0020-7454 print / 1543-5245 online
DOI: 10.3109/00207454.2015.1031749

ORIGINAL ARTICLE

The use of MMSE and MoCA in patients with acute

ischemic stroke in clinical
Yi-Jun Shen,1,2 Wen-An Wang,3 Fu-De Huang,4 Jie Chen,2 Hai-Yan Liu,1,2 Yi-Ling Xia,1,2
Meng Han,1,5 and Le Zhang4
1
Department of Neurology, School of Medicine, Shanghai Jiao Tong University,Shanghai 200092, China; 2 Department of
Neurology, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China;
3
Department of Neurology, Xin Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Chongming
Branch, Shanghai 202150, China; 4 Center for Stem Cell and Nanomedicine, Laboratory for System Biology, Shanghai
Advanced Research Institute, Chinese Academy of Sciences, Shanghai 201210, China; 5 Department of Neurology, The Sixth
People’s Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200233, China

Background: The Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) are
brief cognitive screening tools that have been developed for the screening of patients with Mild Cognitive Im-
pairment. Methods: A total of 105 patients were included in this study, aged 53–89 years, with acute ischemic
stroke admitted to hospital and fell into two groups: stroke patients with cognitive impairment (SCI) and con-
trols with no cognitive impairment (n-SCI). The patient’s characteristics are collected and regression analyses
were performed to predict cognitive impairments. We use MMSE and MoCA assessment as prognostic indices
for cognitive impairments of patient’s with stroke. Objectives: Our aim was to examine the effectiveness of the
MMSE and MoCA in screening cognitive impairments. Main results: There were significant difference among
the two groups in the prevalence of diabetes mellitus (p < 0.05) and intracranial atherosclerosis (p < 0.05). A
linear regression determined that the age, diabetes, intracranial atherosclerosis predicted the cognitive impair-
ments. The ROC results for MoCA with an AUC of 0.882 and the corresponding results for MMSE show a similar
AUC of 0.839. Conclusion: Neuropsychological performance of stroke patients was influenced by biological and
demographic variables: age, diabetes and intracranial atherosclerosis. The MoCA and MMSE are both reliable
assessments for the diagnosis of cognitive impairment after stroke.
KEYWORDS: acute ischemic stroke, MMSE, MoCA

Introduction ten underestimated by both clinicians and researchers

Stroke is a common disease with the incidence rate
increased by 8.7% annually on average in China
[1, 2]. Up to two thirds of persons who have expe-
rienced a stroke have some degree of cognitive im-
pairment which associated with a ninefold increased
risk of dementia in epidemiological studies [3, 4].
This kind of poststroke cognitive impairment is of-
Received 26 June 2014; revised 12 March 2015; accepted 17 March 2015;
publish online 24 September 2015.
Correspondence: Wen-An Wang, Department of Neurology, Xin Hua Hospital
Affiliated to Shanghai Jiao Tong University School of Medicine Chongming
Branch, Shanghai 202150, China. E-mail: wenan wang@163.com and Fu-De
Huang, Center for Stem Cell and Nanomedicine, Laboratory for
SystemBiology, Shanghai Advanced Research Institute, Chinese Academy of
Sciences, Shanghai 201210, China. E-mail: fude huang@yahoo.com
[5, 6]. But cognitive disorders in the acute stage of
stroke are common and powerful independent predic-
tors of adverse outcome in the long term. Diagnose
cognitive deficits at acute stage of stroke, may increas-
ing chances for return to work and improving qual-
ity of life when corresponding treatments were taken.
Early diagnosis of poststroke cognitive impairment and
timely intervention of discrete cognitive disorders is
necessary.
Screening tests are therefore required to improve the
diagnosis of poststroke cognitive impairment. The most
widely used screening tool remains the Mini-Mental
State Examination (MMSE) [7], but it has been
questioned in detecting cognitive impairment after
stroke due to a lack of sensitivity [8]. The Montreal
Cognitive Assessment [9] is a cognitive screening

442

tool specifically developed for the screening of mild
cognitive impairment, which has been developed for
cognitive impairment after stroke and other popula-
tions [10, 11]. Previous studies indicated that the sen-
sitivity of Montreal Cognitive Assessment (MoCA) was
significantly higher to mild cognitive impairment com-
pared with the MMSE, overcoming the limitations of
the MMSE [11–13]. The MoCA is now recognized
as one of the useful cognitive screening tools [14–16]
which has been verified during the experiments in China
[17, 18]. But some study show that both MoCA and
MMSE are moderately sensitive to acute poststroke cog-
nitive impairment [19, 20]. Finally, there is no consen-
sus about these two screening tools, particularly 2 weeks
or less poststroke.
Therefore, objectives were: (1) differences among
groups and predictive variables of cognitive impairments
and (2) the sensitivity and specificity of the MMSE and
MoCA. According to the previous studies, we hypothe-
sized that the MoCA would be more sensitive to cogni-
tive impairment than the MMSE.
Methods
Participants
This study screened all of the consecutive first-ever is-
chemic stroke patients older than 50 years hospitalized
in the Neurology Department of Xinhua Hospital Af-
filiated to Shanghai Jiao Tong University, from January
2013 to June 2014. All stroke occurred within 14 days
before hospitalization and clinical diagnosis of ischemic
stroke was according to Trial of ORG 10172 in Acute
Stroke Treatment [21, 22]. Every patient was ethni-
cally Chinese. Exclusion criteria: computerized tomog-
raphy or MRI confirmed brain organic diseases (cere-
bral hemorrhage, brain tumor). Patients with a history
of other brain disorders (hydrocephalus, intracranial in-
fection, and idiopathic epilepsy). Patients who suffered
serious coexisting disease (heart and lung disease, severe
aphasia, and mental illness). The patient cannot coop-
erate with the examination by doctors (impaired level
of consciousness, vision or hearing loss, and dominant
hand hemiparesis) were excluded. Finally, 105 patients
who met inclusion criteria comprised the final sam-
ple and fell into two groups according to our diagnose
criteria: 67 stroke patients with cognitive impairment
(SCI) and 37 controls with no cognitive impairment
(n-SCI)
Laboratory tests and brain images
Demographic data including age, sex, and education
level, histories of hypertension, diabetes, and atria fibril-

C 2015 Taylor and Francis
The use of MMSE and MoCA in stroke patients 443
lation were obtained from medical records. Laboratory
data including glucose, triglyceride, cholesterol, high-
density lipoprotein (HDL-C), low-density lipoprotein
(LDL-C), and blood pressure were collected. Electro-
cardiogram, carotid ultrasound and cranial MRI were
performed. Past medical history, personal history (past
and current smoking, drinking), and family history
(family members had a history of cerebral infarction or
not) of each patient were collected.
Procedures
All patients also underwent cognitive screening includ-
ing the following: The ADL (Activity of Daily Liv-
ing) scale, NIHSS (National Institutes of Health Stroke
Scale) and mRS (Modified Rankin Scale), CDR (Clin-
ical Dementia Rating), GDS (Global Deterioration
Scale), and HIS (Hachinski). Additionally, we used the
Chinese version of the MoCA and MMSE. The MMSE
and the MoCA are both screening tools for cognitive
impairment that are scored out of 30 and take approx-
imately 10 min to complete. All the procedures per-
formed within two weeks after stroke occurred.
MMSE [7]: The Chinese version MMSE includes
items on orientation to time and place (10 questions),
immediately memory (immediate verbal recall of three
words), calculation (from 100 by 7s), memory (delayed
verbal recall of three words), naming (pencil, watch) and
language (repeat a phrase, follow a written instruction,
follow a three-step command, and write a sentence), and
drawing (copy a line drawing of overlapping pentagons).
MoCA: As compared with the original version, the
contents of Chinese version MoCA had been amended
as follows: The MoCA consists of eight subscales: vi-
suospatial/executive function (alternating Trail-Making,
cube copy, and clock-drawing task), naming (three ani-
mals), memory (only repeat, no points), attention (for-
ward and backward digit span, target detection using
tapping, and a serial subtraction task), language (sen-
tence repetition and verbal fluency), abstraction, de-
layed recall (five nouns, after approximately 5 min), and
orientation (time and place) About MoCA scoring, if
education was less than 12 years, we added 1 point to
the total score [9]).
Participants fell into two groups: SCI and n-SCI.
Clinical diagnostic interviews were conducted by expe-
rienced neurologists and diagnosis of SCI was made ac-
cording to the methods described previously [23, 24].
The diagnostic criteria of SCI were defined as follows:
(1) the patient is neither normal nor demented, did not
meet DSM-IV criteria for the diagnosis of dementia;
(2) subjective cognitive complaint, preferably corrob-
orated by a reliable informant; (3) preserved or mini-
mal impairment in ADL; and (4) preserved global in-
tellectual function and objective cognitive impairment
444 Y. Shen et al.
in the neuropsychological assessment: mainly based on
the CDR, GDS. A global CDR score of 0.5; Level 2
or level 3 in the GDS. Two experienced neurologists
(above 5 years working experience) blinded to the re-
sults of MMSE and MoCA made diagnoses separately
which supplemented by their clinical experiences and
the scores on the mRS, NIHSS, NPI, and HIS.
The criteria of n-SCI were defined as follows: (1) cog-
nitive function was normal and (2) no serious physical
diseases.
Statistical analysis
Statistical analyses of the data were carried out using the
Statistical Package for the Social Sciences (SPSS, ver-
sion 19.0). Descriptive statistics were used for the sam-
ple’s characterization.
Pearson’s χ 2 test was used to determine the group
differences for gender as well as for each of the vascular
risk factors. Age, as well as vascular risk factors was se-
lected to enter the logistic regression analysis to explore
the independent determinants for predicting diagnostic
group classification (SI vs. n-SI).
A receiver operating characteristic (ROC) curve anal-
ysis with area under the curve (AUC) was used to com-
pare the discriminatory ability of the MoCA and MMSE
for SCI and n-SCI. The diagnostic accuracy of the
MoCA and the MMSE for the prediction of the clin-
ical diagnosis of SCI was assessed through the ROCs
curve. To analyze the predictive value of the tests, for
each cutoff point, we calculated the sensitivity, speci-
ficity. Statistical significance was set at p < 0.05 for all
analyses.
Results
General characteristics
Participants’ demographic and clinical characteristics
are listed in Table 1 and 2. A total of 105 patients were
included in the study. Their average age was 68.6 years.
The majority was male (63.8%). 65 patients (58.1%)
had a diagnosis of stroke cognitive impairment and the
rest (n = 40, 41.9%) were stroke patients with no cog-
nitive impairment. SCI patients were older than n-SCI
patients (p < 0.01). There were significant difference
among the two groups in the prevalence of diabetes mel-
litus (DM) (p < 0.05) and intracranial atherosclerosis
(p < 0.05). However, there were no significant differ-
ences between the two groups in gender and the preva-
lence of the remaining vascular risk factors. The SCI and
n-SCI groups differed in MMSE, MoCA, NIHSS, and
ADL scores (p < 0.01).
Sensitivity and Specificity of MMSE
and MoCA
As shown by the standard deviations in Table 1 there
was a statistically significant difference in the mean
scores of both MMSE (22.71 ± 5.83 in SCI group vs.
28.23 ± 1.78 in nSCI group; p < 0.001) and MoCA
(16.45 ± 6.36 in SCI group vs. 24.78 ± 3.42 in nSCI
group; p < 0.001). The ROC results for MoCA with an
AUC of 0.882 confirm that the test has good discrimi-
natory capacity in diagnosing MCI (Table 3). The cor-
responding results for MMSE, which appear in Figure
4, show a similar AUC of 0.839. The comparison of two
ROC curves (z = 0.743, p = 0.453 > 0.05). The sensi-
tivity of MoCA for identifying MCI was similar (0.86)
compared to MMSE, which was 0.82. The specificity
rate for MMSE was 0.78 compared to 0.75 for MoCA.
Discussion
Cognitive impairment after stroke should be detected
early for a possible prediction of dementia and ther-
apeutic purposes. Accurate screening of cognitive im-
pairment at the early stages of stroke is very impor-
tant. Thus, this study aims to validate the sensitivity and
specificity of the MMSE, MoCA. We also wanted to find
the predictive variables of cognitive impairments, con-
sidering the high prevalence rates of stroke. The princi-
pal finding of this study is that the neuropsychological
performance of elderly stroke patients was influenced
by biological and demographic variables. Aging, DM
and intracranial atherosclerosis are all important vascu-
lar risk factor which aggravated cognitive impairments
[25, 26]. These results emphasize the key role of risk
factor for the prevention of cognitive impairment and
specific cognitive function recovery is necessary. No as-
sociations between cognitive impairment and years of
schooling were detected in two groups which is not con-
sistent with previous study. We deduce that cognitive im-
pairment caused by stroke is different with age-related
cognitive impairment. Cognitive impairment caused by
a stroke may be more related to disease itself than the
patients’ knowledge level. We found two group had no
significant cognitive difference when compared smoking
and drinking these two variables. Some studies suggest
that smoking and drinking may be protective for cog-
nitive function [27,28]. The statue of cognitive impair-
ment may be influenced by the quantity, frequency of
smoking and drinking. So the influence of smoking and
alcohol intake on cognition is still a controversial issue
[29]. MMSE and MoCA at the acute stroke phase can
independently predict functional outcome at the early
convalescent stroke phase [30]. The predictive value and
brevity of the MMSE and MoCA warrants their routine
International Journal of Neuroscience
 The use of MMSE and MoCA in stroke patients 445

Table 1. Comparison of baseline characteristics between SCI and n-SCI

Univariate
analysis
Overall SCI nSCI F χ2 p value

Age 68.61 ± 10.35 70.57 ± 9.46 65.43 ± 8.98 0.41 0.007∗

Sex (male/female) 67/39 44/21 23/17 1.10 0.296
HBP (with/without) 74/31 45/20 29/11 0.01 0.914
Level 1 7/98 4/61 3/37 0.28 0.791
Level 2 13/92 7/58 6/34 1.59 0.527
Level 3 54/51 34/31 20/20 0.08 0.820
Diabetes 31/74 24/41 7/33 4.77 0.031∗
(with/without)
IA (with/without) 19/86 16/49 3/37 5.04 0.028∗
Heart disesse 17/88 7/33 10/55 0.10 0.719
(with/without)
Education (year) 8.90 ± 4.24 8.73 ± 4.46 9.20 ± 3.90 2.18 0.419
Smoking 40/65 23/42 17/23 0.52 0.417
Alcohol 20/85 13/52 7/33 0.09 0.754
Family stroke history 6/99 3/62 3/37 0.38 0.541
TG 1.53 ± 0.80 1.56 ± 0.83 1.48 ± 0.75 0.43 0.647
HDL 1.30 ± 0.35 1.31 ± 0.40 1.29 ± 0.26 0.79 0.761
LDL 2.69 ± 0.67 2.75 ± 0.60 2.60 ± 0.75 1.51 0.264
MMSE 24.81 ± 5.42 22.71 ± 5.83 28.23 ± 1.78 29.35 0.000∗
MoCA 19.62 ± 6.76 16.45 ± 6.36 24.78 ± 3.42 23.11 0.000∗
NIH 2.62 ± 2.70 3.16 ± 3.04 1.48 ± 1.12 18.34 0.012∗
ADL 84.44 ± 18.14 81.46 ± 20.37 90.65 ± 10.03 15.56 0.045∗

SCI: stroke cognitive impairment group; n-SCI: nonstroke impairment cognitive group; HBP: high blood pressure; IA: intracranial
atherosclerosis; TG: triglyceride, cholesterol; HDL: high-density lipoprotein; LDL: low-density lipoprotein; NIH: National Institutes
of Health Stroke Scale; ADL: Activity of Daily Living; ∗p < 0.05.

use in the early acute stroke trials. Therefore, the find-
ings established in this study can guide early interven-
tion from baseline to further time after stroke.
One of the objectives of this study was to compare
the sensitivity and specificity of MoCA and the MMSE
scores in persons with stroke. In our data, the MMSE
had sensitivity of 0.82 and specificity of 0.78 at its op-
timal cut-off of 27/28, and the MoCA had sensitivity of
0.86 and specificity of 0.75 at the cut-off of 23/24. So
the sensitivity of MMSE is slightly lower than MoCA.
Cognitive impairment of stroke patients in general with
slowed processing speed, and impairments in executive
function. MMSE is relatively more insensitive in sub-
jects with cerebrovascular disease than amnestic disease,
such as early Alzheimer’s disease. And MMSE is less
capable of testing for complex cognitive impairments
in domains such as visuospatial, executive function and
abstract reasoning. But when the criterion standard clas-
sification was altered to detect only more severely cogni-
tively impaired patients, the MoCA’s superiority in sen-
sitivity was lost due to MMSE has higher specificity than
the MoCA.
ROC analysis was performed to determine the opti-
mal cutoffs for MMSE and MoCA. The optimal cut-
off point for the MMSE (27/28) was higher than that
(26/27) which has been widely recommended. The op-
timal cut-off point for the MoCA (23/24) was lower than
that of the original MoCA (25/26) and of the Japanese
version (25/26), and higher than that of the Korean ver-
sion (22/23). The results of the comparison of two ROC
analyses (p > 0.05) provide support for the contention
that the MoCA and MMSE are both reliable for the di-
agnosis of SCI, with the AUC for MoCA being 0.882
and for MMSE 0.839 which indicate that the short-
comings of the MMSE in stroke may have been over-
stated. MoCA had good sensitivity even at the mild end
of the cognitive impairment spectrum which is an im-
portant quality in a screening tool—so as not to miss

Table 2. Regression estimates of relative contributions of age, diabetes and intracranial atherosclerosis

Parameters Partial regression coefficient Standard error Wald df p Exp(B)

Age 0.60 0.509 6.81 1 0.009∗ 1.062

Diabetes 0.51 0.242 4.45 1 0.035∗ 1.664
IA 0.17 0.083 4.38 1 0.036∗ 1.190

IA: intracranial atherosclerosis; ∗p < 0.05.


C 2015 Taylor and Francis
446 Y. Shen et al.
Table 3 AUC, sensitivity, and specificity of the MMSE and
MoCA
MMSE MoCA
AUC 0.839 IC 95% AUC 0.882 IC 95%
(0.77–0.91) (0.82–0.95)
Cut-off Sensitivity Specificity Cut-off Sensitivity Specificity
26/27 0.72 0.80 22/23 0.80 0.78
27/28∗ 0.82 0.78 23/24∗ 0.86 0.75
28/29 0.85 0.48 25/26 0.95 0.40
∗
Optimal cut-off.
patients who need further assessment. The MMSE was
also a valid tool, with higher specificity than the MoCA
to detect more severely cognitively impaired patients
[30]. Accumulated evidence from our study and pre-
vious studies [19,20] indicates that either MoCA or
MMSE could be used to screen for cognitive impair-
ment at the subacute stroke phase.
There are several limitations of this study. First, our
results depend on a relatively small sample size may
not be generalizable as the majority of patients; sec-
ond, all subjects in this study came from one area of
China (Shanghai) and persons with language impair-
ments, dominant hand hemiparesis were excluded due
to a priori criteria. Third, we employed cognitive screen-
ing tests at baseline, rather than formal neuropsycholog-
ical assessments, for their brevity and utility. We did not
further track cognitive impairment during the rehabil-
itation stage after stroke, so we do not know whether
MMSE and MoCA can be continuous predictors in the
stroke recover course.
In conclusion, it can be speculated that both vascu-
lar risk factors and acute stroke itself increase the pos-
sibility of post-stroke cognitive impairment, which will
be a major challenge in coming years because of the ag-
ing population. Our study underlines that both MoCA
and MMSE were of equivalent discriminatory abilities,
differ from previous comparative studies. Early cogni-
tive screening of patients using either the MMSE or the
MOCA or both could be useful by helping physicians
identify stroke patients with a cognitive impairment. We
are also interested in the relationship of domain-specific
cognitive decline with different stroke origin and work
hard to find the rationale intervention for stroke patients
with cognitive impairment.
Acknowledgements
This study was conducted in conformity with the Dec-
laration of Helsinki. Written informed consent was ob-
tained from all participants and/or legally acceptable
representatives.
Declaration of Interest
On behalf of all authors, the corresponding author states
that there is no conflict of interest. The authors alone are
responsible for the content and writing of the article.
The authors thank the support of Xinhua Hospital
Affiliated to Shanghai Jiao Tong University and Insti-
tute of Neuroscience and State key Laboratory of Neu-
roscience, Shanghai Institutes for Biological Sciences,
Chinese Academy of Sciences.
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