Appendix 114-G Assessment Instruments for Non-Medicaid Home and Community Based Services: Montreal Cognitive Assessment – BLIND (MoCA-BLIND) | HCBS-5300-MANUAL

Read the following instructions to the client. “This is a memory test. I am going to read to you a list of five words to remember. Listen carefully. When I finish, please tell me as many words as you can remember. It doesn’t matter in what order you say them.” [Read list of words below at the rate of 1 word per second. Client repeats them after the last word is read. Check each word the client recalls in the space below]. [Do a second trial even if the client recalls the word(s) on the first trial.] “I am going to read the same words a second time. Try to remember and tell me as many words as you can, including words you said the first time.” No points are given for trials one and two.

Forward Digit Span: Give the following instruction: “I am going to say some numbers and when I am through, repeat them to me exactly as I said them.” Read the five number sequence at a rate of one digit per second. Select “Yes” or “No” from the dropdown to indicate whether the task was completed.

Backward Digit Span: Give the following instruction: “Now I am going to say some more numbers, but when I am through you must repeat them to me in the backwards order.” Read the three number sequence at a rate of one digit per second. Select “Yes” or “No” from the dropdown to indicate whether the task was completed.

Vigilance: Give the following instruction: “I am going to read a sequence of letters. Every time I say the letter A, tap your hand once. If I say a different letter, do not tap your hand.” Read the list of letters at a rate of one per second. Give one point if there is zero to one error (an error is a tap on a wrong letter or a failure to tap on letter A).

Serial 7 Subtraction: Give the following instruction: “Now I will ask you to count by subtracting seven from 100, and then, keep subtracting seven from your answer until I tell you to stop.” Give the instruction twice if necessary. This item is scored out of 3 points. Give 0 points for no correct subtractions, 1 point for one correct subtraction, 2 points for two to three correct subtractions, and 3 points if the client successfully makes four or five correct subtractions. Each subtraction is counted independently; that is, if the client responds with an incorrect number but continues to correctly subtract 7 from it, give a point for each correct subtraction.

Sentence repetition: Give the following instructions: “I am going to read you a sentence. Repeat it after me, exactly as I say it [pause]: I only know that John is the one to help today.” Following the response, say: “Now I am going to read you another sentence. Repeat it after me, exactly as I say it [pause]: The cat always hid under the couch when dogs were in the room.” Check “Yes” or “No” for each sentence correctly repeated. Repetition must be exact.

Fluency: Give the following instructions: “Tell me as many words as you can think of that begin with a certain letter of alphabet that I will tell you in a moment. You can say any kind of word you want except for proper nouns (like Bob or Boston), numbers, or words that begin with the same sound but have a different suffix (for example, love, lover, loving). I will tell you to stop after one minute. Are you ready?” [Pause] Now, tell me as many words as you can think of that begin with the letter F [time for 60 seconds]. Stop.” Write the number of words that client generates. The system will automatically compute a score, with 11 being needed to award 1 point.

Ask the client to explain what pairs of words have in common, starting with the example: “Tell me how an orange and a banana are alike.” If the client answers in a concrete manner, then say only one additional time: “Tell me another way in which those items are alike.” If the subject does not give the appropriate response (fruit), say “Yes, and they are also both fruit.” Do not give any additional instructions or clarification. After the practice trial, say: “Now tell me how a train and a bicycle are alike.” Following the response, administer the second trial, saying; “Now tell me how a ruler and a watch are alike.” Do not give any additional instructions or prompts. Select “Yes” or “No” to indicate a correct response for each pair correctly answered. The following responses are acceptable:

The following responses are not acceptable:

Give the following instruction: “I read some words to you earlier, which I asked you to remember. Tell me as many of those words as you can remember.” Select “Yes” or “No” for each word the client correctly remembers.

At this time, do not use the Category cue or the Multiple Choice cue.

Give the following instruction to the client: “Tell me the date today.” If the client does not give a complete answer, then prompt accordingly by saying: “Tell me the [year, month, exact date, and day of the week].” Then say: “Now, tell me the name of the place and which city it is in.” Select “Yes” or “No” for whether each component of the question was answered correctly. The client must state the exact date and exact place.

The system will add 1 point for an individual who has 12 years or fewer of formal education.

A score of 22 or higher is considered normal. Change the status to “Complete” when done.

It is recommended that the results from the MoCA-BLIND be printed and given to the client and/or caregiver to take to his/her physician for further evaluation.