Journal of the Neurological Sciences 412 (2020) 116735

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Journal of the Neurological Sciences

journal homepage: www.elsevier.com/locate/jns

Concordance of Mini-Mental State Examination, Montreal Cognitive T

Assessment and Parkinson Neuropsychometric Dementia Assessment in the
classification of cognitive performance in Parkinson's disease
Jannik Florian Scheffelsa, Leon Fröhlichb, Elke Kalbec, , Josef Kesslera
⁎

a
Clinic and Polyclinic for Neurology, University Hospital Cologne, University of Cologne, Cologne, Germany
b
Cologne University of Applied Sciences, faculty: Economics and Law, Cologne, Germany
c
Medical Psychology | Neuropsychology and Gender Studies & Centrum for Neuropsychological Diagnostics and Intervention (CeNDI), Medical Faculty and University
Hospital Cologne, University of Cologne, Cologne, Germany

ARTICLE INFO ABSTRACT

Keywords: Background: Cognitive impairment (CI) is frequently observed in Parkinson's disease (PD) and negatively in-
Cognitive screening fluences the patient's and carer's quality of life. As a first step, assessment of CI is often accomplished by using
Concordance screening instruments (level I diagnosis). Three commonly used instruments are the Mini-Mental State
Parkinson's disease Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Parkinson Neuropsychometric Dementia
Parkinson Neuropsychometric Dementia
Assessment (PANDA). Because different preferences regarding test selection exist between clinics, this study
Assessment
Montreal Cognitive Assessment
aims to provide evidence about the concordance of these tests. It also converts total test scores of the three
Mini-Mental State Examination instruments to assist clinical practice.
Methods: Between January and December 2018, 96 patients with idiopathic PD were examined at the University
Hospital of Cologne, Germany. Comparability of MMSE, MoCA, and PANDA scores was investigated by calcu-
lating correlations, classification agreements, and percentile ranks. Additionally, we converted test scores among
the three screening instruments by implementing the equipercentile equating method and log-linear smoothing.
Results: The MMSE classified 26%, the PANDA 32.3% and the MoCA 54.2% of PD patients as having CI. The
screening instruments' concordance in classifying cognition into normal cognition versus CI was 75%
(AC1 = 0.62) for MMSE and PANDA, 63.5% (AC1 = 0.28) for MoCA and PANDA, and 57.3% (AC1 = 0.24) for
MMSE and MoCA. The provided conversion table enables a quick and easy transformation of the three screening
instruments within PD diagnostics.
Conclusion: These results contribute to a better understanding of the screenings' utility and concordance in a
population of PD patients. Additionally, communication between clinics may be enhanced.

1. Introduction
Cognitive impairment (CI) is frequent in Parkinson's disease (PD). It
often is already present at disease onset and may even precede PD di-
agnosis [1]. The severity, extent, and pattern of cognitive symptoms is
heterogeneous [2] and can vary from mild cognitive impairment (MCI)
in one or more cognitive domains to severe dementia (Parkinson's
disease dementia; PDD) [3,4]. The point prevalence of suffering from
PDD varies from 25 to 30% [5], whereas the estimated risk of devel-
oping dementia in PD is five times greater than in the general
population [6], with increasing age being a relevant predictor [7].
Cumulative prevalence rates of PDD in twenty-year survivors can even
reach up to 80% [8]. Although all cognitive domains may be affected in
PD, and multi-domain impairment is observed in up to 35% of de novo
patients [9], greater impairment is typically observed in executive
functions, attention, visuo-spatial skills, and memory [10]. Although
language is less frequently affected compared to impairments in Alz-
heimer's disease, language is still an important domain that should be
investigated. Overall, CI does not only impair the patients' but also the
carers' quality of life [11].

Abbreviations: BDI-II, Beck Depression Inventory-II; CI, Cognitive impairment; MCI, Mild cognitive impairment; MMSE, Mini-Mental State Examination; MoCA,
Montreal Cognitive Assessment; NC, Normal cognition; PANDA, Parkinson Neuropsychometric Dementia Assessment; PD, Parkinson's disease; PDD, Parkinson's
disease dementia
⁎
Corresponding author at: University Hospital Cologne, Kerpener Str. 62, D-50937 Cologne, Germany.
E-mail address: elke.kalbe@uk-koeln.de (E. Kalbe).

https://doi.org/10.1016/j.jns.2020.116735
Received 29 October 2019; Received in revised form 7 February 2020; Accepted 12 February 2020
Available online 13 February 2020
0022-510X/ © 2020 Elsevier B.V. All rights reserved.
J.F. Scheffels, et al.
Due to time and financial constraints, assessment of CI is frequently
done using short cognitive screening instruments that serve as a first
step (for recommended scales, see [12]). For instance, instruments
targeting generic cognition such as the Mini-Mental State Examination
(MMSE) [13] or the Montreal Cognitive Assessment (MoCA) [14] are
used because they provide a broad estimation of cognitive status within
a few minutes.
The most widely used screening instrument is the MMSE, which is
used in various languages and contains a 30-point scale. The assessment
takes about 5 to 10 min. Cut-off scores for dementia defined as 24 to 26
out of 30 possible points are commonly used (for a systematic review,
see [15]). Higher scores are interpreted as normal cognitive func-
tioning. The MMSE includes tasks to assess orientation in time and
place, visuo-construction, memory, language, and apractic aspects.
Education and age corrections exist but are usually not considered [16].
Overall, although the MMSE has been used consistently in PD stu-
dies [17], the MoCA is more appropriate due to its psychometric
properties [17–21]. A recent study by Vásquez and colleagues [22]
showed that 80% of their PD patients had abnormal performance on the
MoCA while being evaluated as age adequate by the MMSE. Ad-
ditionally, the MoCA can be used specifically for assessing MCI because
it is sensitive to cognitive changes [21,23,24]. On the MoCA, as on the
MMSE, a maximum of 30 points can be achieved. It assesses various
aspects of cognitive functioning such as visuo-spatial abilities, naming,
memory, language, abstraction, and orientation. Implementation
duration is about 10 min. For the general population, a cut-off score of
26 points or more is interpreted as age equivalent performance. Edu-
cational effects on test scores are considered by adding one more point
to the total score in people with 12 or fewer years of education. The
MoCA is provided in various languages, although there are not always
sufficient norms available.
However, this generic cognitive screening instrument was not spe-
cifically developed for PD patients. Although the MoCA assesses im-
pairments highly prevalent in those patients (e.g., executive dysfunc-
tions), results in these domains are not sufficiently incorporated into
the total score (that is, they receive too few points) [25,26]. Therefore,
an alternative scoring system for PD patients has been proposed. Ad-
ditionally, there is disagreement about possible MoCA cut-off scores
that can be used within PD diagnostics (for different proposed cut-off
scores see [19,20,27]). Another important point is that both the MMSE
and MoCA only provide cut-off scores for differentiating between
normal cognitive functioning (NC) and cognitive impairment but not
between subtypes of cognitive impairments—for instance, MCI and
PDD.
The Parkinson Neuropsychometric Dementia Assessment (PANDA)
[28] is a more recent screening instrument developed especially for
cognitive symptoms in PD. It comprises a number of subtests, including
paired association learning with immediate and delayed recall, an al-
ternating semantic word fluency task, as well as spatial imagery and
working memory tasks. Within 8 to 10 min these tasks assess specific
domains – especially executive dysfunctions – having high prevalence
in PD. A maximum of 30 points can be achieved. A total score of 18 to
30 points is interpreted as normal cognition (NC). The PANDA also
provides cut-off scores for classifying patients into either having MCI
(15 to 17 points) or cognitive impairment probably indicating dementia
(0 to 14 points). Norms for adults below 59 years and above 60 years of
age are available. A short mood questionnaire included on the PANDA
can evaluate three central aspects of depressive symptoms (mood, in-
terest, drive) and can be administered independently from the cognition
part. The test is validated in German and French [29]. However, since
the PANDA has not been used very frequently in PD research, extensive
clinimetric evaluation is lacking [30].
Despite the shortcomings of these three screening instruments, they
are used frequently within PD diagnostics in neurological clinics.
Unfortunately, it is not clear yet to what extent their results are
equivalent (e.g., classification agreement). To the best of our
2
Journal of the Neurological Sciences 412 (2020) 116735
knowledge, the MMSE, MoCA, and PANDA together have neither pre-
viously been compared in this regard within a population of PD patients
nor in a healthy sample. Additionally, despite validation of all three
screening instruments in French, comparisons are lacking for this lan-
guage. In the context of PD research, there are several studies com-
paring the equivalence of the MoCA and MMSE by mainly focusing on
psychometric aspects such as sensitivity and specificity, test-retest re-
liability, and convergent validity, or by providing conversion tables for
translating a test score on one instrument into an equivalent score on
another instrument [31–35]. However, the PD-specific PANDA, which
is widely established in Germany, was not included in either of the
studies. Moreover, the three tests' score distributions and their (dis)
agreements in the classification of patients' cognitive status have not
been compared yet. This, however, would be useful because clinics
have different preferences concerning the selection of cognitive
screenings. For instance, some clinics prefer to use generic cognitive
screenings (e.g., the MMSE or MoCA) while others prefer disease-spe-
cific instruments (such as the PANDA). This might ultimately present a
challenge when patients are screened for cognitive deficits in different
clinics (e.g., for diagnosis confirmation or follow-up assessments) that
do not use the same instruments. Therefore, it would be useful to define
the equivalence of three commonly used screening instruments within
PD diagnostics to contribute to a better understanding of the screenings'
utility as well as to facilitate communication between clinics by
1.) investigating and comparing the screenings' results (correlations,
sociodemographic effects, score distributions, percentile ranks)
2.) comparing their classification agreement in differentiating between
NC vs. CI, as well as
3.) providing a conversion table for the three screening instruments.
2. Methods
2.1. Subjects
Patients were recruited between January and December 2018. A
total of 96 patients with idiopathic PD diagnosed according to the
clinical criteria of the UK Parkinson's Disease Society Brain Bank [36]
were included. They were in- and out-patients from the Clinic and
Policlinic for Neurology of the University Hospital of Cologne, Ger-
many, and were assessed in the course of the routine neuropsycholo-
gical examination by the neuropsychology work group's staff. Severity
of motor symptoms was equivalent to Hoehn and Yahr stage II to IV and
patients were in the “on” phase of dopaminergic medication. Sample
characteristics are summarized in Table 1. For assessing cognitive
performances subjects were examined on the same day with, in addition
to other instruments, the PANDA, MoCA, and MMSE (German adapta-
tion: [37]). Affect was evaluated with the Beck Depression Inventory-II
Table 1
Sociodemographics and neuropsychological test scores.
Clinical characteristics N = 96
Age (years) 63.15 ± 11.36
Sex, male 67.7
Education ≥12 years 32.3
Education < 12 years 67.7
Cognition
MMSE [range] 27.59 ± 2.13 [16–30]
MoCA [range] 24.12 ± 3.70 [15–30]
PANDA [range] 19.86 ± 6.04 [6–30]
Affect
BDI-II [range] 11.90 ± 8.65 [0–42]
Values in means ± standard deviation for continuous variables and %
for categorical variables. MMSE Mini-Mental State Examination,
PANDA Parkinson Neuropsychometric Dementia Assessment, MoCA
Montreal Cognitive Assessment, BDI-II Beck Depression Inventory-II.
J.F. Scheffels, et al.
[38] among others. Test administration did not take place in a fixed
order to prevent exhaustion effects on test scores of specific tests.
2.2. Statistical analysis
Patients' demographics, total score distributions, and percentile
ranks of the screenings as well as their concordance values were ob-
tained by using SPSS Statistics 25 (for a summary of demographics, see
Table 1). Initially, patients' sociodemographics and scores on the neu-
ropsychological tests were computed. Correlations between screening
instruments as well as age effects were investigated with Spearman‘s
rank correlation coefficient, whereas for education and gender effects
nonparametric Mann-Whitney U tests were used. For reviewing the
comparability of the screening instruments in rating patients’ cognitive
status, classification agreement regarding NC and CI was checked. For
this purpose, the number of patients who were classified by all instru-
ments into NC and CI (agreements), as well as those who were classified
as NC by one and as CI by the other instrument (disagreements) were
calculated and summarized in contingency tables. In addition to the
exact percentage agreements, we calculated first-order agreement
coefficients in Microsoft Excel. These are also known as the Gwet's AC1
statistic and are used to adjust for chance agreement (that is, some
portion of the screenings' classification agreements might be due to
chance). Gwet's AC1 can range from 0 (no agreement) to 1 (perfect
agreement) and is calculated with the following formula [39].
p e( )
Gwet s AC1 =
1 e( ) (1)
Here, p represents the overall percent agreement
A+D
p=
N (2)
with A being the number of times both screening instruments classify a
subject into category 1 (CI), D being the number of times both screening
instruments classify a subject into category 2 (NC), and N representing
the total sample size. In Gwet's AC1, e(ɣ) is the chance agreement
probability
e ( ) = 2q (q 1) (3)
with
A1 + B1
q=
2N (4)
where A1 is the number of subjects classified into category 1 (NC) by
both screening instruments plus the number of subjects classified by the
first instrument (e.g., MMSE) into category 1 (NC) and by the second
instrument (e.g., MoCA) into category 2 (CI), and B1 is the number of
subjects classified into category 1 (NC) by both screening instruments
plus the number of subjects classified by the first instrument into ca-
tegory 2 (CI) and by the second instrument into category 1 (NC). Gwet's
AC1 statistic instead of Cohen's Kappa was chosen since it provides
more stable reliability coefficients and it is less affected by a low pre-
valence of cases [40].
Finally, for a conversion of test scores between MMSE, MoCA, and
PANDA, we implemented the equipercentile equating method and log-
linear smoothing using R version 3.4.3 (equate-package) [41].
3. Results
3.1. Sociodemographics, neuropsychological test results and correlations
The subjects' sociodemographics and neuropsychological scores are
shown in Table 1. PANDA and MoCA scores (r = 0.44), MMSE and
MoCA scores (r = 0.60) as well as MMSE and PANDA scores (r = 0.33)
were highly correlated (respectively p < .001). Correlations between
cognitive instruments and the affective screening BDI-II were not
3
Journal of the Neurological Sciences 412 (2020) 116735
significant: MMSE (r = −0.03, p = .78), MoCA (r = 0.10, p = .38) and
PANDA (r = 0.02, p = .89).
3.2. Sociodemographic effects on test scores
Additionally, age, gender and education effects on total scores were
investigated. It should be noted that the PANDA total score already in-
cludes age, and the MoCA score includes education adjustments. Using
Spearman's rank correlation coefficient, the patients' age showed a sig-
nificant negative correlation with the MoCA (r = −0.33, p < .001) as
well as the MMSE (r = −0.38, p < .001). As expected, due to age
correction, PANDA scores were not significantly correlated with age
(r = −0.11, p = .30). Gender and education (≥12 vs. < 12 years) ef-
fects on test scores were tested by Mann-Whitney U tests. There were no
significant gender differences in scores of the MMSE (Z = −0.65,
p = .52), MoCA (Z = −0.44, p = .66), or PANDA (Z = −0.80,
p = .42), but patients with 12 or more years of education scored sig-
nificantly higher than subjects with fewer years of education on the
MMSE (Z = −2.17, p = .03, r = 0.22) and (despite education corrected
scores) MoCA (Z = −2.01, p = .05, r = 0.21). No differences in scores
related to education on the PANDA (Z = −0.62, p = .54) were found.
3.3. Score distributions and percentile ranks of MMSE, MoCA and PANDA
The distributions of total MMSE, MoCA and PANDA scores are
shown in Fig. 1-3. Median values were 28 for the MMSE, 25 for the
MoCA and 21 for the PANDA, indicating that at least 50% of patients
were evaluated as having CI by the MoCA, since 25 points falls below
the cut-off score. The variability of test scores between instruments was
compared by calculating the interquartile range, which was 3 for the
MMSE, 5.75 for the MoCA and 8.75 for the PANDA. Thus, scores on the
PANDA were the most widely distributed, showing that it is less prone
to ceiling effects (i.e., it is more cognitively demanding) than the gen-
eric cognitive screening instruments MoCA and MMSE. This finding was
supported after calculating the corresponding percentile ranks (Fig. 4):
the curve for the MMSE is the steepest, followed by the MoCA and
PANDA. For instance, subjects with a test result of 25 points reached a
percentile rank of 8.9% on the MMSE, 50% on the MoCA, and 79.7% on
the PANDA.
3.4. Concordance of the screenings' cut-off scores for NC and CI
By generating contingency tables, classification agreement of the
three instruments on patients' cognitive status was compared based on
their classification into NC and CI (ranging from severe to mild deficits).
In our PD sample, 26% are interpreted as having CI by the MMSE,
32.3% by the PANDA, and 54.2% by the MoCA. As shown in Table 2,
MMSE and PANDA showed the highest agreement (75%), mostly be-
cause both evaluated patients as having NC in 65.6% of cases. Here,
96.9% of patients who scored above the PANDA cut-off score for NC
also reached the respective cut-off score on the MMSE. Most disagree-
ment between the two came from patients being judged as having CI by
the PANDA and NC by the MMSE. MoCA and PANDA agreed in their
classification into NC and CI in 63.5% of cases. The highest disagree-
ment came from the classification into NC by the PANDA but CI by the
MoCA (29.2%). Concordance of the MoCA and MMSE showed the same
pattern: in 57.3% of cases both agreed in their classification, whereas a
high percentage of subjects (42.7%) scored normal on the MMSE but
not on the MoCA. No patient was evaluated as having CI by the MMSE
an NC by the MoCA.
Besides exact percentage agreements between the screening in-
struments, first-order agreement coefficients were calculated by using
Gwet's formula [39] in order to adjust for chance agreement and to
increase precision of our results. We found an AC1 of 0.62 for MMSE
and PANDA, 0.28 for MoCA and PANDA as well as 0.24 for MoCA and
MMSE.
J.F. Scheffels, et al.
Fig. 1. Distribution of MMSE scores.
For a comparison with the previously mentioned study by Vásquez
and colleagues [23] showing that 80% of their PD patients (N = 40)
had abnormal performance on the MoCA (defined as a total score
of < 26 points) while being evaluated as age adequate by the MMSE
(total score of ≥24 points), we performed the above analyses with the
same cut-off scores used in this article. In our PD sample, 94 out of 96
patients were classified as NC by the MMSE. In addition, 64.9% of these
patients showed CI as evaluated by the MoCA, which is slightly less
than in the previous PD sample.
3.5. Conversions of PANDA, MoCA and MMSE total scores
A conversion table was generated using the equipercentile equating
method and log-linear smoothing (see Table 3). A comprehensive de-
scription of this method can be found elsewhere [42]. Generally, test
Fig. 2. Distribution of MoCA scores.
4
Journal of the Neurological Sciences 412 (2020) 116735
scores of standardized measures can be regarded as equal when their
respective percentile ranks are similar within the same population (for a
practical example, see [43]). For instance, a person who scores 23 on
the MoCA reaches a percentile rank of 37% in our PD sample, meaning
that 63% of people in this sample scored higher on this measure (see
Fig. 4). In the same cohort, the percentile rank distribution might be
different for the MMSE: here, a patient with a score of 27 falls within an
equal percentile rank (37%) because the MMSE is cognitively less de-
manding than the MoCA. The same applies for the PANDA: a total score
of 18 again means a percentile rank of 37%. Using this rationale, total
scores on all three screening instruments can be equated. An advantage
of the equipercentile equating method is that equivalent scores are al-
ways within an interval of achievable scores. However, irregular score
distributions are possible [44]. To ensure a normal distribution, log-
linear smoothing of each measure's raw scores is needed [45], leading
J.F. Scheffels, et al.
Fig. 3. Distribution of PANDA scores.
to higher equating accuracy [42].
When reviewing the following conversion table, it should be noted
that the transformed scores in italics (PANDA < 7, MMSE < 23 and
MoCA < 16) are estimated values due to few PD patients falling into
the low score spectrum. For this reason, linear interpolation was used
for test scores outside the 0.5% percentile, as advised by Kolen and
Brennan [42]. The given values should therefore be interpreted with
caution. As can be seen in Table 2, a PANDA score of 18 points is, for
instance, equivalent to a score of 23 on the MoCA and 27 on the MMSE.
For each test score in one of the three screenings, the equivalent score
on another instrument can be looked up.
4. Discussion
This work compared the concordance of three commonly used
Fig. 4. Distribution of MMSE, MoCA and PANDA scores in relation to their percentile rank. For instance, a percentile rank of 37% (y-axis) means a total score of 18 on
the PANDA, 23 on the MoCA and 27 on the MMSE.
5
Journal of the Neurological Sciences 412 (2020) 116735
screening instruments within PD diagnostics – MMSE, MoCA and
PANDA – measuring generic cognition (MMSE and MoCA) versus dis-
ease-specific cognitive domains (PANDA). We aimed to compare the
screenings' general characteristics and their classification agreement
into NC and CI as well as to provide a conversion table for total scores
to add to the understanding of their equivalence as well as to assist
clinical practice.
All screening instruments were highly correlated. There were no
gender effects on test scores. However, age and education effects were
found for MoCA (which already includes education correction) and
MMSE scores, but not for PANDA scores (already including age cor-
rection as proposed by the instrument). Based on our analyses, adding
one point on the MoCA to the total score in people with 12 or fewer
years of education therefore seems not enough to correct for education
effects, at least in PD patients. The finding that people with higher age
J.F. Scheffels, et al. Journal of the Neurological Sciences 412 (2020) 116735

Table 2
Percentage of patients classified into NC and CI by MMSE, MoCA and PANDA (N = 96).
PANDA MMSE

NC (18–30 points) CI (0–17 points) NC (26–30 points) CI (0–25 points)

MoCA NC (26–30 points) 38.5 7.3 45.8 0

CI (0–25 points) 29.2 25 42.7 11.5
MMSE NC (26–30 points) 65.6 22.9 – –
CI (0–25 points) 2.1 9.4 – –

Values in %. MMSE Mini-Mental State Examination, MoCA Montreal Cognitive Assessment, PANDA Parkinson Neuropsychometric Dementia Assessment, NC normal
cognition, CI cognitive impairment.

Table 3 the MoCA is “stricter” than the other screenings in evaluating patients'
Conversion table of PANDA, MMSE and MoCA total scores in the PD po- cognitive performance. The screenings' concordance in classifying
pulation (N = 96). cognition into NC versus CI was 75% (AC1 = 0.62) for MMSE and
PANDA MMSE MoCA PANDA, 63.5% (AC1 = 0.28) for MoCA and PANDA, and 57.3%
(AC1 = 0.24) for MMSE and MoCA. According to the criteria developed
1 1 1 by Landis and Koch [47], classification agreement between MMSE and
2 5 4
PANDA can be interpreted as “substantial”, whereas agreements be-
3 9 7
4 14 9 tween MoCA and PANDA as well as MMSE and MoCA are “fair”. The
5 18 12 relatively high classification agreement between PANDA and MMSE
6 22 15 comes from evaluating cognitive performance as NC, because patients
7 23 16 who score high on the PANDA will probably also score high on the
8 23 16
9 24 17
easier MMSE (96.9% in our PD sample).
10 24 18 We showed that a high proportion of patients (64.9%) who were
11 25 19 classified as having normal cognition by the MMSE (≥ 24 points)
12 25 19 scored abnormal on the MoCA (< 26 points). This is in line with a study
13 25 20
by Vásquez and colleagues [23], who found that as much as 80% of
14 26 21
15 26 21 their patients showed this pattern. Together with the ceiling effects
16 27 22 shown in this study, these results highlight the deficiency of the MMSE
17 27 23 in evaluating patients' cognitive performance.
18 27 23 It has to be emphasized that the definition of CI varies with the
19 28 24
20 28 24
choice of the screening instrument (as well as the cognitive subdomains
21 28 25 tested and their cut-off scores for classifying MCI). Different cut-off
22 29 26 scores than those we used - PANDA < 18, MMSE < 26, MoCA < 26 -
23 29 26 would logically have an influence on the screenings' sensitivity as well
24 29 27
as specificity and, consequently, would reveal different results con-
25 29 27
26 30 28 cerning their classification and concordance values (see [48]). There-
27 30 28 fore, the percentages we give here should not be regarded strictly as
28 30 29 representing the “true” classification (dis)agreements of the screenings
29 30 29 but rather as a general pattern: the PANDA, MMSE and MoCA diverge
30 30 30
to a great extent in their interpretation of the PD patients' cognitive
MoCA scores were adjusted for educational level. PANDA scores were performances, especially when it comes to the classification into CI.
corrected for age and educational level. Italic scores are interpolated data, In our transformation of test scores, we used the equipercentile
scores in bold are considered as normal cognition by the respective equating method which has been used frequently for similar purposes.
screening instrument. MMSE Mini-Mental State Examination, MoCA An advantage of this method is that it can handle non-linear scales.
Montreal Cognitive Assessment, PANDA Parkinson Neuropsychometric Therefore, the calculated equivalent test scores will always fall within a
Dementia Assessment range of possible scores, which is not always the case with other tra-
ditional equating methods [49]. However, there can be an irregular
score lower on the MoCA is consistent with a recent study by Barnish distribution of test scores, which was prevented in prior studies by
and colleagues [46] on epidemiological factors influencing this using log-linear smoothing (e.g., [33,34,49]). Another important ad-
screening instrument and again underlines the importance of ac- vantage of our approach here is enhanced flexibility in clinical practice
counting for sociodemographics when interpreting test scores. The due to the conversion table offered. It guarantees continuity in patient
median MoCA value in their study was 25, a result we also observed in status determination by enabling a standardized comparison of a pa-
our PD population. Since this score falls below the suggested cut-off tient's prior test scores (repeated measures), even when different in-
score of < 26, at least 50% of patients had an abnormal MoCA score, struments are used. This might be of interest when patients' cognitive
which is more than in the MMSE (median value 25) and PANDA performance is screened in more than one clinic and, therefore, dif-
(median value 21). ferent measures are used.
The PANDA showed the most widely distributed test scores, fol- However, the equipercentile equating method by no means provides
lowed by the MoCA and MMSE, demonstrating that the latter is more complete concordance between screenings. This is due to the screen-
prone to ceiling effects (meaning that it is less cognitively demanding) ings' differences in the examined cognitive domains and different
and is less able to detect subtle cognitive changes than the other in- scoring methods. For instance, the MoCA includes executive aspects
struments. These results were supported by the calculated percentile that are not measured by the MMSE (word fluency and abstraction).
ranks. In our PD population, 11.5% were interpreted as having CI by the The PANDA measures executive functions to an even greater extent
MMSE, 32.3% by the PANDA, and 54.2% by the MoCA, indicating that than the MoCA by additionally including a spatial imagery task

6
J.F. Scheffels, et al.
(measuring visuo-cognition and executive aspects) as well as pair-as-
sociation, alternating word fluency, and working memory tasks. In
contrast, the MMSE assesses apractic aspects as well as speech com-
prehension by implementing a motor task (folding a sheet of paper) that
are not considered in the other instruments. Lastly, naming as well as
visuo-construction is examined by the MoCA (cube copying) and MMSE
(copying interlocking pentagons) but not by the PANDA. Therefore,
specific comparisons of the screenings' subdomains would have been of
interest as well but, since available data (patients' sociodemographics
and total test scores) was used retrospectively, it was not possible in the
present study. Another difference between the three screening instru-
ments is the scoring method. On the PANDA, scores are weighted per
task and added to a total score, which includes age norms for people
below 60 years of age as well as 60 years and above. On the two other
measures, scores are simply added to a total score. For education cor-
rection, one point is added to the total score of the MoCA when edu-
cation is less than 12 years. Due to these differences in assessed cog-
nitive domains and the scoring methods implemented, the provided
conversion table does not serve as a one-to-one translation of test scores
but as a good orientation and first step in the diagnostic process.
Additionally, the calculated scores in our table are comparable to
those from Steenoven and colleagues [31] as well as Lawton et al. [32],
who also converted scores between MoCA and MMSE in a PD cohort.
Particularly for high scores they are very similar, although PD samples
with different cultural backgrounds were used. In both samples, con-
versions at the cut-off scores for both screenings revealed the same
results: 25/26 points on the MMSE are equivalent to 20/21 points on
the MoCA (21/22 points in the study by Lawton et al.), and 25/26
points on the MoCA are converted into 28/29 points on the MMSE (28/
28 points in Lawton et al.).
Finally, it should be stressed that, generally, a comprehensive
neuropsychological assessment of the patient's cognition cannot be re-
placed with short screening instruments. In the context of PD, assess-
ments of cognitive deficits should always be in line with the diagnostic
criteria provided by the Movement Disorder Society Task Force [2] as
well as the diagnostic criteria for dementia associated with PD [50] to
be able to recognize patients with PD-MCI as early as possible and to
identify those at increased risk of PDD development. The method of
choice (level I category: utilization of short screening instruments vs.
level II category: comprehensive assessment) depends on the diagnostic
purpose (e.g., certainty of PD-MCI diagnosis or PD-MCI subtyping for
research) as well as the clinics' capabilities, but should definitely in-
clude a scale validated for use in PD and measure (at least some of) the
following five cognitive domains: attention and memory, executive
functions, language, memory, and visuo-spatial functions.
To summarize, test scores of short screening instruments can be
used in clinical practice at level I, and if a patient scores below the
critical cut-off score, level II testing should be implemented. In line with
this principle, this study does not aim to promote using short cognitive
screening instruments but to improve diagnostic certainty in level I
testing, which appropriately will lead to examination for level II only
when it is really needed.
Ethics
This work has been carried out in accordance with The Code of
Ethics of the World Medical Association (Declaration of Helsinki, 1975)
for experiments involving humans. The privacy rights of human sub-
jects were observed, since this work is a retrospective, “quasi-epide-
miological” study using patient data completely blinded.
Declarations of Competing Interest
None.
7
Journal of the Neurological Sciences 412 (2020) 116735
Study funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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