Supplementary Material for: Differences in Cognitive Profile between TIA, Stroke and Elderly Memory Research Subjects: A Comparison of the MMSE and MoCA

<b><i>Background:</i></b> The Montreal Cognitive Assessment (MoCA) appears more sensitive to mild cognitive impairment (MCI) than the Mini-Mental State Examination (MMSE): over 50% of TIA and stroke patients with an MMSE score of ≥27 (‘normal’ cognitive function) at ≥6 months after index event, score &lt;26 on the MoCA, a cutoff which has good sensitivity and specificity for MCI in this population. We hypothesized that sensitivity of the MoCA to MCI might in part be due to detection of different patterns of cognitive domain impairment. We therefore compared performance on the MMSE and MoCA in subjects without major cognitive impairment (MMSE score of ≥24) with differing clinical characteristics: a TIA and stroke cohort in which frontal/executive deficits were expected to be prevalent and a memory research cohort. <b><i>Methods:</i></b> The MMSE and MoCA were done on consecutive patients with TIA or stroke in a population-based study (Oxford Vascular Study) 6 months or more after the index event and on consecutive subjects enrolled in a memory research cohort (the Oxford Project to Investigate Memory and Ageing). Patients with moderate-to-severe cognitive impairment (MMSE score of &lt;24), dysphasia or inability to use the dominant arm were excluded. <b><i>Results:</i></b> Of 207 stroke patients (mean age ± SD: 72 ± 11.5 years, 54% male), 156 TIA patients (mean age 71 ± 12.1 years, 53% male) and 107 memory research subjects (mean age 76 ± 6.6 years, 46% male), stroke patients had the lowest mean ± SD cognitive scores (MMSE score of 27.7 ± 1.84 and MoCA score of 22.9 ± 3.6), whereas TIA (MMSE score of 28.4 ± 1.7 and MoCA score of 24.9 ± 3.3) and memory subject scores (MMSE score of 28.5 ± 1.7 and MoCA score of 25.5 ± 3.0) were more similar. Rates of MoCA score of &lt;26 in subjects with normal MMSE ( ≥27) were lowest in memory subjects, intermediate in TIA and highest after stroke (34 vs. 48 vs. 67%, p &lt; 0.001). The cerebrovascular patients scored lower than the memory subjects on all MoCA frontal/executive subtests with differences being most marked in visuoexecutive function, verbal fluency and sustained attention (all p &lt; 0.0001) and in stroke versus TIA (after adjustment for age and education). Stroke patients performed worse than TIA patients only on MMSE orientation in contrast to 6/10 subtests of the MoCA. Results were similar after restricting analyses to those with an MMSE score of ≥27. <b><i>Conclusions:</i></b> The MoCA demonstrated more differences in cognitive profile between TIA, stroke and memory research subjects without major cognitive impairment than the MMSE. The MoCA showed between-group differences even in those with normal MMSE and would thus appear to be a useful brief tool to assess cognition in those with MCI, particularly where the ceiling effect of the MMSE is problematic.

<b><i>背景：</i></b> 相较于简易精神状态检查表（Mini-Mental State Examination, MMSE），蒙特利尔认知评估量表（Montreal Cognitive Assessment, MoCA）对轻度认知障碍（mild cognitive impairment, MCI）的检出敏感性更高。超过50%的短暂性脑缺血发作（transient ischemic attack, TIA）及脑卒中患者，在首发事件发生≥6个月后，MMSE评分≥27分（被判定为认知功能正常），但MoCA评分却＜26分；该MoCA划界分在此类人群中对MCI具有良好的敏感性与特异性。我们提出假设：MoCA对MCI的较高敏感性，部分源于其可识别不同类型的认知域损害模式。因此，我们针对无重度认知障碍（MMSE评分≥24分）且临床特征存在差异的受试者，比较了MMSE与MoCA的测评表现：一组为预期额叶/执行功能损害高发的TIA及脑卒中队列，另一组为记忆研究队列。<b><i>方法：</i></b> 本研究在一项基于人群的研究——牛津血管研究（Oxford Vascular Study）中，对首发事件发生6个月及以上的连续性TIA或脑卒中患者，以及纳入牛津记忆与衰老研究项目（Oxford Project to Investigate Memory and Ageing）的连续性记忆研究队列受试者，均完成了MMSE与MoCA测评。排除存在中度至重度认知障碍（MMSE评分＜24分）、失语或无法使用利手的患者。<b><i>结果：</i></b> 本研究共纳入207例脑卒中患者（平均年龄±标准差：72±11.5岁，男性占比54%）、156例TIA患者（平均年龄71±12.1岁，男性占比53%）以及107例记忆研究受试者（平均年龄76±6.6岁，男性占比46%）。脑卒中患者的平均认知评分最低（MMSE评分27.7±1.84，MoCA评分22.9±3.6）；而TIA患者（MMSE评分28.4±1.7，MoCA评分24.9±3.3）与记忆研究受试者的评分（MMSE评分28.5±1.7，MoCA评分25.5±3.0）更为接近。在MMSE评分正常（≥27分）的受试者中，MoCA评分＜26分的比例在记忆研究受试者中最低，TIA患者中居中，脑卒中患者中最高（分别为34%、48%、67%，p＜0.001）。脑血管病患者在MoCA所有额叶/执行功能分项测验中的得分均低于记忆研究受试者，其中以视执行功能、言语流畅性及持续性注意力的差异最为显著（所有p＜0.0001）；校正年龄与教育程度后，脑卒中患者与TIA患者的上述差异同样存在。相较于仅在MMSE定向力分项上弱于TIA患者，脑卒中患者在MoCA的10个分项测验中有6个表现更差。将分析范围限定在MMSE评分≥27分的受试者时，上述结果保持一致。<b><i>结论：</i></b> 相较于MMSE，MoCA可更清晰地区分无重度认知障碍的TIA、脑卒中患者与记忆研究受试者之间的认知特征差异。即使在MMSE评分正常的人群中，MoCA仍能检出组间差异，因此其作为一款便捷的认知测评工具，可有效用于MCI的评估，尤其适用于MMSE存在天花板效应的场景。