Last year, Dr. Ronny Jackson, then the White House physician, gave Donald Trump a standard test to detect early signs of dementia — and said the president had scored a perfect 30. “There is no indication whatsoever that he has any cognitive issues,” Jackson said at the time in front of TV cameras.

Trump’s team embraced the result, with Donald Jr. boasting on Twitter: “More #winning.” The publicity sparked a wave of interest in the screening tool. Much was written about what the test showed – or didn’t – about the president’s mental acuity. A media outlet even posted its questions online, suggesting readers could measure whether they were “fit to be U.S. president.”

Dr. Ziad Nasreddine, the creator of that test, the Montreal Cognitive Assessment, went with it. Within weeks, the Lebanese-Canadian neurologist and his colleagues were working on “mini-MoCA,” an online exam for anyone to take who was worried about his own cognitive decline. Nasreddine said at the time that he might charge the masses $1 or $2 per test.

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Now Nasreddine has changed course. He says growing worries about the validity of test results — and possible liability for errors — have pressed him to require those who administer the test to pay for mandatory certification to make sure the results are accurate.

Further examination of the results called into question even perfect scores.

“I’ve seen so much variability, which might make us reconsider some of the decisions made based on the MoCA score,” said Nasreddine, who has reviewed hundreds of exams administered to patients in recent years.

Training and certification have been voluntary for years. But starting Sept. 1, most clinicians who administer the MoCA will be required to complete a one-hour, $125 online course, said Nasreddine, who holds the copyright to the test.

Nasreddine, director of the MoCA Clinic and Institute in Quebec, Canada, wouldn’t speculate about whether Trump’s test was accurate. Officials with the White House and the Navy, where Jackson is a rear admiral, did not respond to questions about the issue. Jackson did not reply to an email seeking comment.

The move to require certification — and particularly to charge for it — sparked outrage among geriatricians like Dr. Eric Widera of the University of California, San Francisco. He accused Nasreddine of creating a “pay to play” scenario that profits from a growing need and the test’s ubiquitous use.

“It raises huge red flags,” Widera said. “This is a growing issue, the monetization of tools that we promoted as the standard.”

It’s a controversial change for an exam that is used by doctors and other health professionals in nearly 200 countries to screen people for potential problems with memory and thinking.

In the U.S., the MoCA is a go-to tool used in about 8,000 visits each year to the 31 Alzheimer’s Disease Research Centers funded by the National Institute on Aging. The 30-question test assesses different cognitive domains through exercises that include drawing a cube, drawing a clock with hands set at a specific time, naming certain animals, memorizing a series of words and calculating numbers in a certain way.

Until now, the MoCA screen has been free for clinicians, making it a cheap, easy way to tell if someone should proceed to the more detailed evaluations used to make an actual diagnosis of dementia.

After Sept. 1, 2020 — a year after the training requirement begins — access to the test will be restricted to certified users, Nasreddine said. Only medical students, residents and fellows, and neuropsychologists will be exempt. Two-year recertification is optional and will be offered at half the original cost. Group rates will be available for institutions and government bodies to make the training affordable.

Still, Widera said he worries that requiring MoCA certification will deter nonspecialists from testing for early signs of dementia.

Studies estimate that somewhere between about 500,000 and 1 million Americans age 65 or older will develop Alzheimer’s disease this year.

Nasreddine said he has seen testing errors after reviewing hundreds of MoCA exams given by doctors and others who didn’t properly follow a four-page list of directions.

A MoCA score of 26 or higher is generally considered normal, while a score of 18 to 25 can indicate mild cognitive impairment, and 10 to 17 can indicate moderate impairment. A score of less than 10 indicates severe impairment.

On some tests, scores varied by as much as five points in the same patient over a few weeks, Nasreddine said.

“That is a lot of points out of 30,” he said. “If it’s within the same month, it’s not because the disease changed that quickly.”

Widera and others acknowledged that errors can occur in administering and interpreting the MoCA or any tool.

“There may be operator error,” he said. “That’s true for everything we do in medicine. Nobody licenses us every two years to use a stethoscope.”

Nasreddine said he and his team have been threatened with lawsuits — though it appears no cases have been filed — by people who said they were harmed by the results of tests given by health professionals who lack specialized dementia training.

“One man, they stripped him of his legal rights, put him in the nursing home, all because he scored 15 or 20 on the MoCA test,” said Nasreddine, who in addition to running a memory clinic is an assistant clinical professor at McGill University and University of Sherbrooke in Canada.

A nurse who had been having mild attention problems lost her job “because the psychiatrist who ran the test on her was not trained and didn’t do it well,” Nasreddine said, adding, “They’re blaming us.”

Regular users of the MoCA likened the controversy over the exam to the recent fate of another cognitive screening tool, the Mini-Mental State Examination.

That test, known as the MMSE, was used widely for 30 years before its authors began enforcing copyright protection and then granted an exclusive license to a third-party firm. A licensed version of the MMSE is now sold for $89 for a package of 50 tests.

The parallel upset experts like Dr. Louise Aronson, a UCSF professor of geriatrics and author of the best-selling book “Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life.”

“First we gave up the #MMSE and now we will renounce the #MOCA,” Aronson tweeted on June 28. “Lessons in putting profit ahead of patients and #healthcare. Disappointing is the most polite word I can think of.”

Nasreddine said he has received many emails from MoCA users happy with the mandatory certification, adding that “the purpose of the training is to make the test more reliable and valid.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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  • Negative expectations (following the knowledge of one’s disease risk) have been found to significantly influence disease development – this happens through powerful ‘nocebo’ effects. The following randomized study examined how the knowledge of a risk can be physiologically more damaging than having that risk itself:

    Turnwald, B. P. et al. (2019). Learning one’s genetic risk changes physiology independent of actual genetic risk. Nature Human Behaviour, 3(1), 48.

    So, I wonder how much damage we are doing by labeling people about having a terrible disease – I am sure people who are terrified of being diagnosed are the ones who perform badly in this test as well.

  • I appreciate the heads-up in this article. Because it cited the September 1 target date, I went to the MoCA site right away. They make it sound as though the training & certification (+ every 2-year recert!) are already a fait accomplit. However, there is an option to decline them & sign a disclaimer before you can download the app or paper copy of any of the versions. I haven’t used the MoCA in the outpatient setting because it is so time consuming, but had been thinking about it for people who do poorly on the “6-CIT” (don’t bother if you don’t know it- we use it because Qualis offers a pre-printed version for our Medicare AWV screens, but it’s terrible) or MMSE. I just wanted to download a copy of the Basic MoCA (low-literacy, but NOT low academic training or low complexity) & the FIVE pages of instructions for possible future use.

  • One needs to take into account many things in interpreting a test like this. Is the room comfortable or too cold, is the patient relaxed and focused or anxious and flighty, how educated is the tested person, what medications does the person use and many other factors. That said, as a geriatrician I can state that it is helpful if significantly abnormal if not too relied on.

  • I’ve taken this test twice because it’s offerred for free at a local clinic. My father had Alzheimer’s so I have a mild and somewhat curious concern about myself. What surprised me is that the test is the exactly the same every time. So as I sat for my second yearly session I recalled many of the facts about the detailed story that I had heard the prior year. I basically knew what I was going to be asked to recall about the story and my mind was conditioned to remember the details…in other words, I was in test mode and I knew what was coming next with naming the animals, etc. Maybe that alone precludes a dementia diagnosis for me but it makes me wonder about the possible error in repeated testing on the same subject. So my simple recommendation to the MoCA is that a variety of test versions should be developed to avoid the possibility of skewed results on the same subject.

    • There are already multiple MoCA tests, expressly for that purpose; they say specifically for people being retested frequently

  • I think simply receiving a so-called “diagnosis” (i.e., being told that one has “Alzheimer’s”) itself is very stressful and to think that this negative labeling of people is based merely on a cognitive test is devastating. What if the person has test anxiety or a stressful episode in life that prevents them from doing the test well? Giving patients labels take away hopes for recovery, and disempower people (and labels can also activate ‘nocebo’ effects – which are opposite of powerful placebo effects). Labels also increase stigma – stigma and discrimination exists when people distinguish and give labels to human differences that are associated with negative stereotypes. Also, recent studies have demonstrated that interventions that decrease psychological stress have the potential to prevent or reverse Alzheimer’s/Parkinson’s.

    Hanson, L. R. et al., Mindfulness for early Alzheimer’s Disease: A Pilot study. Alzheimers Dement. 13, P1410-P1411 (2017).

    Kwok, J. Y., et al. (2019). Effects of mindfulness yoga vs stretching and resistance training exercises on anxiety and depression for people with Parkinson disease: a randomized clinical trial. JAMA neurology.

    Quintana-Hernández, D. J. et al., Mindfulness in the maintenance of cognitive capacities in Alzheimer’s disease: a randomized clinical trial. J Alzheimers Dis. 50, 217-232 (2016).

  • I’ve taken the test.I believe it is too hard overall. Things like naming 10 animals in a minute. Remembering 5 things, and then repeating later. I think it may be good for alzheimers if you score 20 or less. I really doubt Trump got a 30.

    • Doctors already have to be relicensed every 2 years (CA) and re-boarded (every 10 for Family Medicine). This would be like having to (pay for) training on using your flashlight or thermometer every two years.

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