A Comparison of Computerized and Paper and Pencil Versions of the Montreal Cognitive Assessment (MoCA)

PURPOSE: Cognitive assessment tools that evaluate individuals across multiple domains are critical to the diagnosis, treatment planning, and re-evaluation. Despite potential advantages of computerized cognitive assessments, a need exists to compare each newly developed cognitive assessment to paper and pencil versions (Wild, Howieson, Webbe, Seelye, & Kaye, 2008). Clinicians administer these types of cognitive assessments to older adults because of changes in cognition due to normal aging or the suspected onset of a condition such as dementia. However, little is known about the usability of computerized assessments by older individuals and how this may influence performance (García-Casal, et al., 2017). The purpose of this study was to compare the results of the Montreal Cognitive Assessment (MoCA) paper version and electronic, tablet-based version when administered to older adults. Additionally, we considered factors related to participant preferences and familiarity with touchscreens.

DESIGN: The study was an exploration of older adults’ performance on cognitive assessments. To be included, participants had to be over the age of 65 years, and have hearing, vision and motor skills necessary to interact with the touchscreen. Participants were excluded if they had a severe cognitive impairment as evidenced by a score of <10 on the Mini Mental State Exam (MMSE).

METHOD: After participants completed informed consent and the screenings, both versions of the MoCA (i.e., paper and tablet) were administered in a randomized order, followed by a questionnaire. Descriptive statistics on demographics and data from the preference questionnaire were completed using means and standard deviations. Performance across participants was compared using ANOVAs and t-tests as indicated with an alpha level of 0.05. Additional correlations between iPad and paper performance as well as iPad comfort and iPad performance were completed.

RESULTS: We analyzed data from 40 older adults with an average age of 75 years. The average MMSE score was 28.29/30 (Range: 21-30) and at least half of the participants reported previously using a touchscreen device. Using a mixed-design ANOVA results showed a significant 3-way interaction for presentation order, presentation modality, and cognitive domains (F=29.29, df=1, p<.01) and 2-way interaction for presentation order and presentation modality (F=7.64, df=1, p<.01). However, post-hoc t-tests indicated there was no statistically significant difference between performance of those who had the iPad first and those who took the paper version first (t=8.26, df=1, p=.076). The differences in performance when comparing those who completed iPad first to paper first were most pronounced on the visuospatial executive tasks that required direct use of a stylus to interact with the tablet (t=25.25, df=1, p=.03). There was a strong correlation between performance on paper MoCA and iPad MoCA (R = 0.677) and a moderate correlation between iPad MoCA score and touchscreen experience (R = 0.423). Finally, despite the correlation between touchscreen experience and performance, >75% of participants reported feeling comfortable with the iPad. Furthermore, 50% of participants indicated no preference between iPad or paper administration.

CONCLUSION: The findings of this study demonstrate that presentation modality, specifically using a touchscreen, impacts performance on a commonly used cognitive screen.

IMPACT STATEMENT: While the difference between performance on these tests was small on average, a one-point difference is clinically significant when determining cognitive status. Therapists would benefit from considering touchscreen experience over preference or comfort when deciding whether to use an electronic version of a test.

References

Wild, K., Howieson, D., Webbe, F., Seelye, A., & Kaye, J. (2008). The status of computerized cognitive testing in aging: A systematic review. Alzheimer’s and Dementia, 4(6), 428–437. doi:10.1016/j.jalz.2008.07.003

García-Casal, J. A., Loizeau, A., Csipke, E., Franco-Martín, M., Perea-Bartolomé, M. V., & Orrell, M. (2017). Computer-based cognitive interventions for people living with dementia: A systematic literature review and meta-analysis. Aging & Mental Health, 21(5), 454–467. doi:10.1080/13607863.2015.1132677