Improving diagnostic accuracy of the Montreal Cognitive Assessment to identify post-stroke cognitive impairment

Given advantages in reperfusion therapy leading to mild stroke, less apparent cognitive deficits can be overseen in a routine neurological examination. Despite the widespread use of the Montreal Cognitive Assessment (MoCA), age- and education-specific cutoffs for the detection of post-stroke cognitive impairment (PSCI) are not established, hampering its valid application in stroke. We aimed to establish age- and education-specific MoCA cutoffs to better discriminate patients with and without acute PSCI. Patients with acute ischemic stroke underwent the MoCA and a detailed neuropsychological assessment. PSCI was defined as a performance < - 1.5 SD in >= 2 cognitive domains. As secondary data analysis, the discriminant abilities of the MoCAraw-score (not adding + 1 as correction for <= 12 years of education, YoE) cutoffs were automatically derived based on Youden Index and evaluated by receiver operating characteristic analyses across age- (< 55, 55-70, > 70 years old) and education-specific (<= 12 and > 12 YoE) groups. 351 stroke patients (67.4 +/- 14.1 years old; 13.1 +/- 2.8 YoE) underwent the neuropsychological assessment 2.7 +/- 2.0 days post-stroke. The original MoCA cutoff < 26 falsely classified 26.2% of examined patients, with poor sensitivity in younger adults (34.8% in patients < 55 years > 12 YoE) and poor specificity in older adults (55.0%, in > 70 years <= 12 YoE). By maximizing both sensitivity and specificity, the optimal MoCAraw cutoffs were: (i) < 28 in patients aged < 55 with > 12 YoE (sensitivity = 69.6%, specificity = 77.8%); (ii) < 22 and < 25 in patients > 70 years with <= 12 and > 12 YoE (sensitivity = 61.6%, specificity = 90.0%; sensitivity = 63.3%, specificity = 84.0%, respectively). In other groups the optimal MoCAraw cutoff was < 26. Age and education level should be considered when interpreting MoCA-scores. Though new age- and education-specific cutoffs demonstrated higher discriminant ability for PSCI, their performance in young stroke and adults with higher education level was low due to ceiling effects and MoCA subtests structure, and cautious interpretation in these patients is warranted. Trial registration: ClinicalTrials.gov Identifier: NCT05653141.