The Montreal Cognitive Assessment (MoCA): updated norms and psychometric insights into adaptive testing from healthy individuals in Northern Italy

Aiello, Edoardo Nicolò; Gramegna, Chiara; Esposito, Antonella; Gazzaniga, Valentina; Zago, Stefano; Difonzo, Teresa; Maddaluno, Ottavia; Appollonio, Ildebrando; Bolognini, Nadia · 2021 · OpenAlex-citations

DOI: 10.1007/s40520-021-01943-7

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Summary

This study addresses the need for updated, region-specific normative data for the Montreal Cognitive Assessment (MoCA) in Northern Italy. While the MoCA is a widely used screening tool for mild cognitive impairment, interpreting scores requires fine-grained, culture-specific psychometric outcomes. The authors aimed to provide updated norms for the Italian MoCA, compare them to existing norms with broader geographical coverage, and analyze the sensitivity and discriminative capability of individual test items using Item Response Theory (IRT). The study recruited 579 healthy Italian native speakers from Lombardy, Northern Italy, aged 21 to 96 years. Participants were excluded if they had neurological or psychiatric disorders, severe medical conditions affecting cognition, or were taking psychotropic drugs. The Italian version of the MoCA was administered, assessing domains including executive functioning, attention, language, visuo-spatial abilities, orientation, and memory. Statistical analyses included the Equivalent Scores (ES) method to derive normative values adjusted for age and education, and a two-parameter logistic IRT model to evaluate item difficulty and discrimination. The study also compared the new ES classifications with previous Italian norms using Cohen’s kappa. Results indicated that age and education significantly predicted performance on all MoCA measures, except for Orientation, which was predicted by age only. No significant sex differences were found when controlling for age and education, although raw scores showed slight male advantages in attention, language, and visuo-spatial domains. The new normative classifications showed substantial disagreement with previous Italian norms, suggesting regional differences. IRT analysis revealed that memory items and certain executive function and orientation items had high discriminative capability. Conversely, the "place" item in Orientation and the letter detection task were found to be scarcely sensitive and had low discrimination values. The most difficult items included the three-dimensional cube copy and delayed recall tasks, while the easiest included the clock drawing contour and naming familiar animals. The significance of this work lies in providing Italian practitioners with updated, region-specific norms and item-level insights that facilitate more accurate interpretation of MoCA scores. The findings highlight that previous norms may not be applicable to Northern Italian populations due to regional and demographic differences. The identification of low-sensitivity items suggests that practitioners should consider adaptive testing approaches, weighting items differently based on their psychometric properties. This study underscores the importance of regularly updating normative data to account for socio-demographic changes and regional variations, thereby improving the diagnostic utility of cognitive screening tools in clinical practice.

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• cognitive impairment