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Correlation Between The Indonesian Versions of Montreal Cognitive

Assessment (MoCA-INA) and Visual Cognitive Assessment Test (VCAT-INA)
as Cognitive Screening Tools

Article in International Journal of Human and Health Sciences (IJHHS) · January 2022
DOI: 10.31344/ijhhs.v6i1.376

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 International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

Original article:

Correlation Between The Indonesian Versions of Montreal Cognitive Assessment (MoCA-INA)

and Visual Cognitive Assessment Test (VCAT-INA) as Cognitive Screening Tools
Fasihah Irfani Fitri1*, Aldy S Rambe 1, Paulus Anam Ong2 , Ika Mariana Gultom 1

Abstract

Background and purpose: Screening for cognitive impairment has become increasingly
important as the population ages, especially using tools that is not mainly affected my
translational process so it can be used in multilingual population. The aim of this study
was to determine the correlation between the Indonesian version of Montreal Cognitive
Assessment (MoCA-INA) and Visual Cognitive Assessment Test (VCAT-INA) as
cognitive screening tools. Methods: This was a cross sectional study involving subjects
recruited for cognitive screening in general population and memory clinic Adam Malik
General Hospital Medan Indonesia between December 2019 and April 2020. All subjects
underwent physical and neurologic examination and cognitive assessment including
MoCA-INA and VCAT-INA, that was adapted from the original version. Results: A total
of 104 subjects were studied, consisted of 41 (39.4%) males and 63 (60.4%) females. The
mean age of subjects was 64.4±10.07 years and ranged from 41-82 years. Most of the
subjects had 12 years of education (45 subjects; 43.3%). Most of the subjects had abnormal
MoCA-INA and VCAT-INA scores. Both scores showed comparable result but VCAT-
INA showed lower average and a broader range of scores. There was a strong positive
significant correlation between the scores (r=0.815; p < 0.001). Conclusions: MoCA-
INA score is strongly correlated with VCAT-INA score. As visual-based test, VCAT-INA
can be applied as a cognitive screening tool in daily clinical practice without significant
language barrier.

Keywords: cognitive screening, dementia, Montreal cognitive assessment, visual

cognitive assessment test

International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Page : 47-54
DOI: http://dx.doi.org/10.31344/ijhhs.v6i1.376

Introduction ageing population that has become a worldwide

universal concern. The number of elderly people
It is estimated that there are over 50 million people in the world is projected to increase from 420
living with dementia globally, a figure predicted million in 2000 to nearly 1 billion by 2030, with
to increase to 152 million by 2050. Someone the proportion of elderly people increasing from
develops dementia every three seconds and the 7–12%. The most rapid and greatest increase in
current annual cost of dementia is estimated at absolute numbers of older persons will occur in
US $1 trillion, a figure set to double by 2030.1 low- and middle-income countries (LMIC) such
The increased prevalence of dementia is highly as China, India, and other South Asian nations. As
correlated with the growing proportion of the a result, the LMIC share of the worldwide ageing

1. Department of Neurology Faculty of Medicine, Universitas Sumatera Utara, Adam Malik General
Hospital, Medan, Indonesia
2. Department of Neurology Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General
Hospital, Bandung, Indonesia

Correspondence to: Fasihah Irfani Fitri, Email : [email protected], ORCID : 0000-0002-0883-3029

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 International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

population will increase from around 60% to more setting including mild cognitive impairment and
than 70%. Thus, as a strongly age-dependent dementia10,11,elderly population12,13,14,post-stroke
disorder, dementia or Alzheimer’s disease will patients15, parkinson’s disease16, aneurysmal
have a huge impact on public health, healthcare, subarachnoid hemorrhage17, epilepsy18 and HIV-
and social service systems in all countries associated neurocognitive disorders (HANDs).19
throughout the world. Therefore AD has indeed While the MoCA-INA has been translated from the
become a global challenge and remains a global original MoCA and has been culturally validated in
health priority.1-3 Indonesia9, nevertheless, as like any other existing
cognitive screening tools, it was designed for use
The issue of screening for dementia and cognitive in specific language. Cognitive screening tools
impairment will become more increasingly that have been modified and translated more likely
important. Other that the increased prevalence of to result in overdiagnosis of cognitive impairment
AD, the improvements in survival rates following in non-English speakers.20
stroke also mean that there will be an increase
in vascular and post-stroke dementias since The Visual Cognitive Assessment Test (VCAT) is
approximately 30% of stroke patients will develop a cognitive screening tool that is developed as a
dementia.4 Early diagnosis and intervention of visual-based test. Its diagnostic performance and
dementia may allow the patient to compensate discriminative validities were superior compared
for the disability, minimize disease-related and to MMSE and comparable to MoCA. 21 The VCAT
medication complications, improve quality of life has been validated in four southeast asian countries
and optimize the use of resources.5 Screening tests including Indonesia, without language translation
for cognitive impairment in the clinical setting or cultural adaptation. It was found to be effective
generally include asking patients to perform a in discriminating between healthy control and
series of tasks that assess at least 1 cognitive domain subjects with cognitive impairment (MCI and
(memory, attention, language, and visuospatial mild AD dementia).22 The Indonesian version of
or executive functioning). Neuropsychological VCAT, namely VCAT-INA has also showed good
testing is the gold-standard for assessing dementia diagnostic performance in post stroke cognitive
and cognitive impairment, but it is time-consuming impairment, compared to MoCA-INA and
and requires adequate training.6 Therefore it is MMSE-INA.23 No study has yet evaluated its use
as cognitive screening test. The objective of this
highly important for clinicians to use effective
study was mainly to compare and determine the
short cognitive tests as appropriate to the clinical
correlation between the MoCA-INA and VCAT-
setting for suspected dementia.7
INA scores as cognitive screening tool.
One of the most widely used cognitive screening
Materials and Methods
tool currently is the Montreal Cognitive Assessment
(MoCA), that was developed as a brief cognitive This was a cross sectional study involving 104
screening tool to detect mild-moderate cognitive subjects consisted of 71 subjects which were
impairment. The MoCA assess several cognitive recruited from Medan Helvetia District, Medan,
domains including executive fuction, visuospatial North Sumatera, Indonesia, because it was one of
function, attention and concentration, memory, the most densely populated district in Medan and 33
language, calculation and orientation. The subjects recruited from Memory Clinic Neurology
Indonesian version of MoCA, namely MoCA-INA Department Adam Malik General Hospital Medan
has been developed and validated in Indonesia North Sumatera, Indonesia between December
and so it can be used as a cognitive screening 2019 and April 2020. Inclusion criteria were
tool.9 It has been found to have high sensitivity able to speak Bahasa Indonesia fluently, able
and specificity for the detection of mild cognitive to read and write, had no significant vision or
impairment (MCI and mild dementia.10 With a cut- hearing impairments and gave written consent to
off score of 26, the Mini Mental State Examination be included in the study. We excluded subjects
(MMSE) had a sensitivity of 17% to detect who were medically unstable (delirium), had
subjects with MCI, whereas the MoCA detected psychiatric disorders or had an aphasia. All subjects
83%.11 Several previous studies have found the underwent physical and neurologic examination
superiority of MoCA compared to MMSE in and cognitive assessment including MoCA-
detecting cognitive impairment in various clinical INA and VCAT-INA. The MoCA-INA assesses
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 International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

several cognitive domains which are visuospatial/ correlation. Both scores were also compared based
executive, naming, memory, attention, language, on level of education and age group. Our study
abstraction, delayed recall and orientation (to time had been approved by the Faculty of Medicine
and place). Visuospatial abilities are assessed using Universitas Sumatera Utara/Haji Adam Malik
a clock-drawing task and a trail-making task which General Hospital Ethical Committee.
is said to be useful in assessing fitness to drive.
Attention, concentration and working memory are Results
evaluated using a sustained attention task (target
A total of 104 subjects were studied, consisted of 41
detection using tapping), a serial subtraction task
(39.4%) males and 63 (60.4%) females. The mean
and digits forward and backward. Its score range
age of subjects was 64.4±10.07 years and ranged
is 0-30, higher score indicates better cogntive
from 41-82 years. Most of the subjects belong to
performance,and a cut off of more than 26 is
age group of 66-70 years and 71-75 years; each of
considered normal. The MoCA adds one point for
the group consisted of 20 subjects (19.2%). Most
those whose educational level is 12 or fewer years.8
of the subjects had level of education of senior
There are several adjusments of MoCA-INA
high school, meaning had 12 years of education
compared to the original version in assessment of
(45 subjects; 43.3%). There were 24 subjects
naming, memory and delayed recall and language
(23.1%) with normal MoCA-INA score (26-30),
function because of transcultural validation.9
and there was 27 subjects (26%) with normal
The Visual Cognitive Assessment Test is a visual- VCAT-INA score (23-30). Based on VCAT-INA
based cognitive screening tool designed to detect score there was 48 subjects (46.2%) with dementia
early cognitive impairment. It is language neutral (score 0-17) and 29 subjects (27.9%) with MCI
and encourages simple application to multilingual (score 18-22). The characteristics of the subjects
populations without the need for translation of test are shown in Table 1.
content.21 The VCAT is a 30-point test that evaluates
Table 1. Characteristics Data of The Subjects
memory, executive function, visuospatial function,
Frequency
attention, and semantic knowledge. The test items Characteristics
(N=104)
Percentage (%)
for each cognitive domain are visual based, with
Gender
pictures and figures selected from the International Male 41 39.4
Picture Naming Project and locally validated Female 63 60.6
in older adults.22 The episodic memory domain Age (years), Mean + SD 64.4±10.07
consists of seven test items assessing immediate and
Age groups
delayed recall using a scenario, shapes and objects. 41-45 years old 7 6.7
The executive function domain consists of four 46-50 years old 4 3.8
51-55 years old 9 8.7
items evaluating pattern recognition-completion, 56-60 years old 9 8.7
mechanics of gear movement and grouping of 61-65 years old 25 24.0
66-70 years old 20 19.2
pictures based on categories. The visuospatial 71-75 years old 20 19.2
function domain contains two items assessing 76-80 years old 8 7.7
visuospatial abilities via cube reconstruction, >81 years old 2 1.9

visual depth perception and grid navigation. In the Educational Level

Elementary school 15 14.4
language domain with two items, participants were Junior high school 19 18.3
required to name pictures. The semantic fluency Senior high school 45 43.3
were assessed using four categories which were University 25 24.0

countries, vegetables, modes of transport and kitchen MoCA-INA score, Mean +

20.96±4.81
SD
utensils. A symbol recognition cancellation task was
used to assess attention domain. The VCAT scale MoCA-INA
Normal (≥26) 24 23.1
range was 30 with lower score indicating greater Abnormal (<26) 80 76.9
impairment. The cut offs were: normal 23-30, MCI
VCAT-INA score, Mean + SD 18.76±6.09
18-22 and dementia 0-17. 21
VCAT-INA
All statistical procedures were performed with Normal (23-30)
27 25.9
Mild Cognitive
SPSS. The correlation between MoCA-INA and Impairment (18-22)
29 27.9
VCAT-INA scores was measured using the pearson Dementia (<18) 48 46.2

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 International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

The average MoCA-INA score was 20.96±4.81 INA and VCAT-INA scores based on age group
(range 10 to 30). The average VCAT-INA score and level of education.(Table 3). The Pearson’s
was 18.76 ± 6.09 (range 4 to 30). Both scores correlation coefficient between the scores was
showed comparable result but VCAT-INA showed 0.815 (p < 0.001). A graph showing the correlation
lower average and a broader range of scores.(Table between the MoCA-INA and VCAT-INA scores is
2) There was a significant difference in MoCA- shown in Figure 1

Table 2. Comparison of MoCA-INA dan VCAT-INA Scores

Cognitive
Cognitive Domains
Domains Mean±SD Range Mean±SD Range
(VCAT-INA)
(MoCA-INA)

Total 20.96±4.81 10-30 Total 18.76±6.09 4-30

Visuospatial/executive 2.98±1.63 0-5 Memory 8.04±3.12 0-13

Naming 2.76±0.55 0-3 Language 3.92±0.99 1-5

Attention 4.55±1.50 1-6 Visuospatial 2.17±0.84 0-3

Language 2.10±0.86 0-3 Executive Function 3.26±1.68 0-6

Abstraction 1.13±0.67 0-2 Attention 1.30±1.35 0-3

Delayed Recall 1.81±1.19 0-5

Orientation 5.81±0.48 3-6

Table 3. MoCA-INA and VCAT-INA scores

based on age and educational level groups

MoCA-INA VCAT-INA
Score p Score P
Mean±SD Mean±SD

Age groups
41-45 years old 25.00±6.60 25.14±6.61
46-50 years old 26.50±3.31 24.00±6.68
51-55 years old 20.89±4.75 20.33±5.91
56-60 years old 21.67±4.00 19.78±5.78
61-65 years old 21.68±3.56 0.002 18.96±5.56 0.003
66-70 years old 21.55±4.88 19.25±5.49
71-75 years old 18.70±4.24 15.9±5.68
76-80 years old 17.38±4.20 13.88±3.04
>81 years old 15.00±4.24 15.00±8.48 Figure 1. Correlation between MoCA-INA and
Educational Level VCAT-INA scores
Elementary
16.27±3.39 13.13±4.62
school
Junior high Discussion
18.16±3.50 <0.001 15.16±3.53 <0.001
school
Senior high 21.80±3.98 19.07±5.14 Dementia is a disabling syndrome characterized
school
University 24.40±4.55 24.32±5.16 by progressive deterioration in multiple cognitive
ANOVA domains that is severe enough to interfere with
daily functioning, including social and professional
Table 4. Correlation between MoCA-INA and functioning.3 In addition to identifying patients
VCAT-INA Scores who may benefit from pharmacotherapy and non
pharmacologic interventions, early detection of
Variables VCAT-INA
dementia helps families anticipate the patient’s
r P needs and helps physicians identify those in need
MoCA-INA 0.815 <0.001 of additional support.6 As the population ages,

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 International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

there is an increasing need for effective cognitive sensitivity 0f 83.3 and specificity of 65.1. Their
screening that can be widely used in multilingual study also showed the diagnostic performance
population and can be used without significant of VCAT-INA is comparable to MoCA-INA and
language barrier. This study compared the MoCA- MMSE-INA.23
INA and VCAT-INA scores as cognitive screening
tools. The VCAT-INA is adapted from the original The results of this study showed that The MoCA-
VCAT but without significant translation other INA and VCAT-INA showed comparable results
than instructions for the assessors. It is a visual- but VCAT-INA showed lower average with wider
based cognitive test that can be applied in range of scores. Our study found the mean MoCA-
participants with various language.21 INA score was 20.96±4.81 and VCAT-INA
18.76±6.09. These scores were lower than those
Kandiah et al, has developed and studied the reported in previous studies. Study by Kandiah
use of VCAT in multilingual populations to et al found a median score of MoCA 28, VCAT
detect dementia at an early stage and found 26 in healthy control and MoCA 23, VCAT 17 in
that VCAT had good sensitivity and specificity cognitively impaired group, respectively.21 Lim et
for the diagnosis of mild cognitive impairment al reported mean (SD) MOCA 25.52 (3.37) and
(MCI) and mild AD. They validated VCAT in a VCAT 22.48 (3.50) in healthy control and mean
sample comprised of 206 subjects. The diagnostic (SD) MOCA 16.59 (5.75) and VCAT 14.17 (5.05)
performance of VCAT was generally satisfactory in subjects with cognitive impairment.22 These
and comparable to MoCA in sensitivity (85.6%), lower scores might be affected by educational
specificity (81.1%) and overall discriminative level and age although most subjects in our study
ability (AUC=93.3; CI 90.1-96.4) for diagnosis of had level of education of senior high school,
cognitive impairment (MCI and mild AD).21 meaning had at least 12 years of education, but we
also found significant differences in these scores
The VCAT has also been validated in four south based on level of education and age groups. This
southeast asian countries including Indonesia. needs to be evaluated further in future studies.
In a prospective, multicenter study involving
284 participants carried out across Singapore, Interestingly, using either MoCA-INA or VCAT-
Malaysia, Indonesia and Philippines, the VCAT, INA, the proportion of subjects with cognitive
without local translation or adaptation, was found impairment was greater than normal subjects.
to be effective in discriminating between healthy There were 80 subjects (76.9%) subjects with
controls and cognitively impaired subjects. abnormal MoCA-INA score and 77 subjects
Areas under the curve for Montreal Cognitive (74.1%) with abnormal VCAT-INA score, 29
Assessment (0.916, 95% CI 0.884–0.948) and (27.9%) with MCI and 48 (46.2%) with dementia
the VCAT (0.905, 95% CI 0.870–0.940) in respectively. Considering the fact that the
discriminating between healthy controls and subjects in this study were recruited from general
cognitively impaired subjects were comparable. population and memory clinic also, this finding
The multiple languages used to administer VCAT might emphasize the importance of cognitive
in four countries did not significantly influence screening not only in daily clinical practice but
test scores.22 also in general population for early detection of
dementia.
A study by Ong, et al in Indonesia, which included
38 healthy subjects and 91 post-stroke cognitive It can be argued that the main purpose of the
impairment (PSCI) subjects has also found the cognitive screening test is to show the likelihood
satisfactory diagnostic performance test of VCAT- of cognitive dysfunction. It is usually done by
INA: it detected 80.8% of PSCI (AUC 0.734- comparing the patient’s score with the normal
0.882). With cut-off 21, VCAT-INA differentiated reference score in the general population. A very
healthy subjects from PSCI patients with impaired score along with detail history may
sensitivity of 74.7 and specificity of 62.2. Using lead a clinician to make a diagnosis without
cut off 17, VCAT-INA can differentiate PSCI further detailed investigation; a borderline score
non-dementia from those with dementia with may need referral for more comprehensive
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 International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

neuropsychological assessment.4 Although no basis of specific test items might be lost during
single tool is recognized as the “gold standard” translations.21 This issue needs to be studied in
for detection of cognitive impairment, an initial more detail in further studies, but it might give an
structured assessment should provide either a insight in using translated tools in multilingual
baseline for cognitive surveillance or a trigger for populations.
further evaluation.24 Conclusion
The cognitive screening tool is not intended to In conclusion, we found a strong positive
replace a full neuropsychological assessment. It correlation between MoCA-INA and VCAT-INA
can be used to obtain clue about cognitive domains scores. As visual-based test, VCAT-INA can
that are affected in a short assessment time. be applied as a cognitive screening tool in daily
Neuropsychological testing has consistently clinical practice without significant language
shown that subtypes of dementia are characterized barrier.
by different patterns of impairment.4 The VCAT
Declaration of interest and funding disclosure
was designed to detect deficits in wide range of
cognitive domains with greater emphasize on The authors report no conflicts of interest. The
episodic memory and executive function, two of authors alone are responsible for the content and
the most affected domains in eraly AD and VaD, writing of this article. This research did not receive
the two most common type of dementia.21 any financial support.

In population with diverse cultures and languages, Acknowledgement

a cognitive screening tool that is relatively free
This research did not receive any specific grant
from translation bias becomes very important. This from funding agencies in the public, commercial,
study was conducted in Medan, the capital of the or not-for-profit sectors.
province of North Sumatra, which was inhabited
by various tribes in various languages. Although Ethical clearence: Ethical clearance was obtained
with an adequate educational background it can from Faculty of Medicine Universitas Sumatera
be said that knowledge in bahasa Indonesia is also Utara/Haji Adam Malik General Hospital Ethical
Committee.
adequate, but it does not rule out the possibility of
variations in vocabulary understanding and words Author’s contribution: Data gathering, and ideas,
familiarity used in cognitive screening tools, along study design, writing, submitting of manuscript,
with other issues in translated tools for non English editing and approval of final draft, were all events
speakers, as some of the basic neuropsychological conducted by the authors.

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 International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

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