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Adaptation of the Montreal Cognitive Assessment for Elderly Filipino
Patients.
Article in East Asian Archives of Psychiatry · September 2013
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East Asian Arch Psychiatry 2013;23:80-5
Theme Paper
Adaptation of the Montreal Cognitive
Assessment for Elderly Filipino Patients
以菲律賓老年患者為對象的蒙特利爾認知評估量表診斷改編版
JC Dominguez, MGS Orquiza, JR Soriano, CD Magpantay, RC Esteban, ML Corrales, ER Ampil
Abstract
Objective: The Montreal Cognitive Assessment (MoCA) is an instrument that aids clinicians in detecting
mild cognitive impairment and early Alzheimer’s disease. The study aimed to adapt the MoCA for use in
the Philippines, and determine its psychometric validity when used in the Filipino setting.
Methods: The MoCA was adapted by a multidisciplinary team working at the Memory Center of St.
Luke’s Medical Center, Manila, the Philippines. Contextual adaptation, rather than direct translation, was
done. Pilot testing of the Filipino version of the MoCA (MoCA-P) was done on 12 grade 6 pupils and
subsequently on 14 cognitively intact elderly people. Reliability testing of the MoCA-P was done on 25
elderly people by trained psychologists. Internal consistency, inter-rater and intra-rater reliability, as well
as convergent and divergent validity of the MoCA-P were determined.
Results: The MoCA-P yielded a high level of internal consistency (Cronbach’s α = 0.938). Inter-rater and
intra-rater reliability were 0.887 (p ≤ 0.05) and 0.969 (p ≤ 0.05), respectively. The MoCA-P correlated
negatively with the Epworth Sleepiness Scale (r = –0.233) and had a positive but low correlation with the
Mini-Mental State Examination (r = 0.555).
Conclusion: Contextual translation and pilot testing yielded several modifications of the MoCA. The
MoCA-P is a reliable instrument for use in elderly Filipino patients. Further diagnostic validation of the
MoCA-P to establish cutoff scores that would discriminate elderly individuals with normal cognition
from those with dementia is needed to establish the clinical utility of the test.
Key words: Aged; Alzheimer disease; Neuropsychological tests
摘要
目的：蒙特利爾認知評估（MoCA）量表能協助臨床醫生檢測輕度認知障礙和早期阿兹海默
病。本研究旨在把MoCA量表改編菲律賓語版本（MoCA-P），並檢視於當地醫療服務體系使用
的心理效度。
方法：由菲律賓馬尼拉聖路加醫療中心的記憶中心跨部門團隊，採用語境順應而非直接翻譯的
方法改編MoCA量表，先於12名6年級學生和14名認知功能正常的長者進行試點測試，然後由
受過訓練的心理學家向25名長者進行信度測試，以檢視量表的內部一致性、施測者間信度、施
測者內信度，以及聚合效度和分歧效度。
結果：MoCA-P量表產生高內部一致性水平（克隆巴赫系數 = 0.938）。施測者間信度和施測者
內信度分別為0.887（p ≤ 0.05）和0.969（p ≤ 0.05）。MoCA-P量表與愛普沃斯嗜睡量表呈負
相關（r = -0.233），與簡易精神狀態量表則呈正面但低相關性（r = 0.555）。
結論：MoCA-P量表因應語境順應和試點測試作幾番修改，它是診斷菲律賓老年患者的可靠工
具。為實踐研究的臨床應用，須進一步驗證MoCA-P的診斷效度，從而建立可區別認知功能正
常的長者與腦退化症患者的切點。
關鍵詞：長者、阿茲海默病、神經心理學測試
Dr Jacqueline C. Dominguez, MD, Memory Center, International Institute for
Neurosciences, St. Luke’s Medical Center, Manila, Philippines.
Dr Mary Grace S. Orquiza, MS, Memory Center, International Institute for
Neurosciences, St. Luke’s Medical Center, Manila, Philippines.
Dr Jennifer R. Soriano, MS, Memory Center, International Institute for
Neurosciences, St. Luke’s Medical Center, Manila, Philippines.
Dr Cely D. Magpantay, PhD, Memory Center, International Institute for
Neurosciences, St. Luke’s Medical Center, Manila, Philippines.
Dr Rolando C. Esteban, PhD, Research and Biotechnology Division, St. Luke’s
Medical Center, Manila, Philippines.
Dr Ma. Lourdes Corrales, MD, Memory Center, International Institute for
80
Neurosciences, St. Luke’s Medical Center, Manila, Philippines.
Dr Encarnita R. Ampil, MD, Memory Center, International Institute for
Neurosciences, St. Luke’s Medical Center, Manila, Philippines.
Address for correspondence: Dr Jacqueline C. Dominguez, Memory Center,
International Institute for Neurosciences, St. Luke’s Medical Center, 279 E.
Rodriguez Sr. Boulevard, Quezon City, 1102 Philippines.
Tel: (632) 7275558; Fax: (632) 7275559;
email: jcdominguez@stluke.com.ph
Submitted: 4 January 2013; Accepted: 10 June 2013
© 2013 Hong Kong College of Psychiatrists
Montreal Cognitive Assessment for Elderly Filipino Patients
Introduction
Dementia is a progressive brain dysfunction involving
memory, language, gnosis, praxis, and executive function.
The cognitive impairment is sufficient to interfere with a
patient’s ability to function independently.1 Dementia also
causes disturbing behaviours that impair relationships
with others and lead to distress to the family and the
affected individual. The most common form of dementia
is Alzheimer’s disease (AD),2 and age is clearly associated
with an increased risk for AD.3
Since AD develops insidiously and progresses
gradually, it is not uncommon that it goes unnoticed for
many years before disturbing symptoms that merit medical
attention occur. At the onset, when symptoms are mildest
and commonly related to memory decline, such change
is typically dismissed as part of normal ageing. However,
early diagnosis is important as it provides an opportunity for
early drug intervention, which has been shown to improve
cognition4 and function, and may delay deterioration or
institutionalisation in countries where elderly people are
eventually cared for in nursing homes.5 Aside from early
treatment, early diagnosis promotes acceptance and better
understanding of the disease, its symptoms, and its course.
Early diagnosis enables families to better care for their
relative and plan ahead for social, financial, and legal issues
that may arise from a patient’s disabilities.
The cognitive domains that are affected in AD
are orientation, memory, attention, executive function,
language, visuospatial function, visuomotor speed, and
visuoconstruction. Involvement of these domains is defined
and documented through the use of neuropsychological
tests that could help to identify both the impaired and
preserved skills. Given that the core feature of AD is
cognitive impairment, neuropsychological tests are
ancillary to the diagnosis of AD. Most tests are developed
in western English-speaking populations, where they have
been developed from clinical experience and validated
in the local population. Test performance is known to be
influenced by age, education, and language as observed
for the Mini-Mental State Examination (MMSE).6 Values
and beliefs can also affect neuropsychological testing.7 The
issue of how culture and language affect test performance
has been a topic of concern in past decades.8,9 Floor effects
have been apparent when English tests were administered
to non-native populations in the US, particularly because
of the high cultural bias of some of the items found in the
tests.10 Thus, particularly for screening instruments used in
the medical field, cross-cultural adaptation is imperative.
Important aspects in cross-cultural adaptation are reliability,
content, and construct validity. Careful forward translation,
synthesis, back-translation, expert judging, and pre-final
testing components are needed.11,12 Most importantly,
contextual adaptation by using experiential and conceptual
equivalence to the culture where the instrument is being
adapted to must be meticulously accorded.13
In an Asian country such as the Philippines, early
East Asian Arch Psychiatry 2013, Vol 23, No.3
dementia or mild cognitive impairment may not be
detected as some people still regard cognitive decline as
part of normal ageing and elderly people are commonly
spared strenuous or mentally challenging activities. Mild
impairment is also not detected by the validated Filipino
version of the MMSE (MMSE-P).14 There is therefore a
need to adapt a good screening tool in the Philippines to
help clinicians detect dementia early and accurately. This
study aimed to adapt the Montreal Cognitive Assessment
(MoCA)15 and determine the adapted version’s
psychometric reliability among the Filipino elderly.
The MoCA was chosen because it has been shown to be
sensitive to mild cognitive impairment15 and validated
in different languages.16-19 The MoCA has also gained
worldwide acceptability, being recommended as the
screening instrument not only for AD, but also for other
types of dementia such as vascular cognitive impairment
by some professional groups and researchers.20
Methods
Study Design
This was a cross-sectional study conducted at the
Memory Center of St. Luke’s Medical Center in Manila,
the Philippines. This centre is a specialised referral unit
providing assessment and treatment for patients with
dementia and other related disorders. Ethics approval for
the study was granted by the St. Luke’s Medical Center
Institutional Ethics Review Committee. Permission to adapt
the MoCA was obtained from Prof. Ziad Nasreddine, the
primary author of the MoCA.15
Study Population
The study participants for the pilot test were recruited from
grade 6 pupils in a public elementary school and cognitively
intact elderly individuals. The pre-testing participants were
elderly individuals who were different from those in the
pilot tests. The elderly people were recruited from the
Senior Citizen Registry of Marikina, which is an outreach
community of the St. Luke’s International Institute for
Neurosciences. All study participants provided informed
consent before any testing was done.
Procedure
The original version of the MoCA was translated and adapted
by a multidisciplinary team comprising a neurologist, a
geriatrician, 2 psychologists, a geriatric psychiatrist, an
anthropologist, a speech and language therapist, and a
nurse. The members were specifically chosen because of
their knowledge of the concepts and objectives underlying
the test items. All team members are bilingual (English
and Filipino) but their mother tongue is Filipino. Since
the intended users, i.e. the testers who are medical / allied
medical professionals and are English-literate, the guideline
for the test administrators was retained in English, and only
the test instructions that would be read to the participants
were translated into Filipino. To ensure the applicability
81
JC Dominguez, MGS Orquiza, JR Soriano, et al
of test items to the Filipino elderly, contextual adaptation
rather than simple direct translation was done, with careful
consideration of the Filipino culture. The translation
was compared with the original15 to verify cross-cultural
equivalence. This translation was the first version of
the MoCA adaptation. This version was then critiqued
independently by a second multidisciplinary team with the
same qualifications as the translating team. The translation
was also back-translated by a nurse and physician who were
not working at the memory centre and were unacquainted
with the intent of the test.
The critique and comments from the back-translation
were discussed by all members of the 2 teams and
amendments were introduced. The result was the second
version of the MoCA adaptation. This version was then
pilot-tested by grade 6 pupils for comprehensibility of
instructions and ease of delivery. The second version was also
pilot-tested by cognitively intact elderly people. The elderly
participants were assessed by a neurologist to ascertain
absence of dementia based on the National Institute of
Non-communicative Disorders and Stroke — Alzheimer’s
Disease and Related Disorders Association clinical criteria.1
Observations from the pilot tests — particularly semantic,
experiential, and conceptual equivalence with the original
test—were incorporated in the second version. The result
was the third version of the adaptation, which was referred
to as the Filipino version of the MoCA (MoCA-P). All
disagreements throughout the process were resolved by
consensus. The guidelines to preserve equivalence in
cross-cultural adaptation of health-related measures were
followed.21
The cognitively intact elderly people who pretested the MoCA-P returned for re-testing after 2 weeks
to assess retest reliability. The pre-testing was videotaped
and the tapes were viewed and rated independently by
other testers in order to assess inter-rater reliability. The
pre-test participants were also administered the MMSE-P14
and the Epworth Sleepiness Scale to assess for convergent
and divergent validity, respectively. The testers were
psychologists with experience of MoCA test administration.
Statistical Analysis
Internal consistency of the MoCA-P was computed by
Cronbach’s α. Test-retest reliability was assessed using
intraclass correlation coefficients for scores at baseline and
at 2 weeks. Pearson’s correlation scores were calculated to
assess the relationship between the MoCA-P and MMSE-P,
and between the MoCA-P and Epworth Sleepiness Scale.
All statistical analyses were done using the Statistical
Package for the Social Sciences Windows version 17 (SPSS
Inc, Chicago [IL], US). A p value of less than 0.05 was
considered statistically significant for all the analyses.
Results
Twelve grade 6 pupils and 14 cognitively intact elderly
individuals were included in the pilot test and 25 cognitively
82
intact elderly individuals were included in the pre-test. The
elderly participants were community-dwelling and were
representative of the diversity of Filipino communities in
terms of education and ethnicity (Table). All of the elderly
participants were fluent in the Filipino language.
The MoCA translation was fully comprehensible to
the grade 6 pilot participants. However, it was apparent
from the responses of the elderly pilot participants that
linguistic and cultural modifications had to be made.
None among the elderly participants named the rhinoceros
correctly because it seemed that the animal was not within
the realm of their reality and vocabulary. Inability to name
the rhinoceros by the elderly participants appeared to be a
generational issue as all the grade 6 pupils in the pilot test
were able to name the animal with ease. Three animals were
recommended as a replacement for rhinoceros — carabao
(water buffalo), crocodile, and owl. Carabao was too
common, hence easy to identify, while a crocodile’s picture
could be mistakenly named as lizard or alligator. The owl,
which is an indigenous Philippine fauna used with medium
frequency and is distinctly identifiable by its prominently
big round eyes, was chosen by consensus.
In the language subtest, letter fluency with ‘F’ was not
possible as there are no Filipino words that begin with this
letter other than the word Filipino. Thus, the letter B was
chosen. It was also found that word-for-word translation of
the 2 English sentences for repetition unusually lengthened
the text in Filipino, and the long sentences became
challenging tongue twisters. Therefore, the 2 sentences
were carefully abridged while retaining their meaning and
the number of words in the original version.
In the abstraction subtest, the consensus was to
change clock to weighing scale (‘timbangan’). This was
done because the elderly pilot participants did not consider
a clock to be a measuring instrument like a ruler. For these
participants, a clock tells the time, but does not measure time.
The elderly participants also categorised the paired items
based on concrete and physical attributes. For example,
a common response regarding the similarity of a bicycle
and train was that both are made of metal (vs. the correct
original response that both are modes of transportation).
The participants also categorised items from the viewpoint
of what is immediately practical, as in orange and banana
are food (vs. the correct original response that both are
fruits). The responses were not the best answers, but
were nevertheless correct. By consensus agreement, these
responses were considered acceptable and participants
would not be penalised for not thinking in concepts familiar
to western populations. These responses were therefore to
be rated correct in the MoCA-P.
Some modifications of the original test instructions
were also introduced. The test sheet was folded crosswise
to hide the pictures of the animals to be named because the
participants were distracted by them. Another modification
was made to the abstraction subtest, for which participants
needed repetition to understand the instruction. Therefore,
repetition of the instructions up to 2 times was allowed and
East Asian Arch Psychiatry 2013, Vol 23, No.3
Montreal Cognitive Assessment for Elderly Filipino Patients
Table. Demographic profile of pilot and pre-test groups.*
Demographics
Sex
Female
Male
Age (years)
10-12
60-69
70-79
80-89
Education level (years)
Elementary (1-6)
High school (7-10)
College (11-14)
Postgraduate (≥ 15)
Ethnicity
Tagalog
Bicolano
Bisaya
Kapampangan
Ilocano
*
†
Pilot testing of grade 6
pupils (n = 12)
Pilot testing of elderly
people† (n = 14)
Pre-testing of elderly
people† (n = 25)
5 (42%)
7 (58%)
11.5 ± 0.5
12 (100%)
6±0
12 (100%)
-
7 (50%)
7 (50%)
69.6 ± 4.4
5 (36%)
9 (64%)
0
9.8 ± 3.5
4 (28%)
5 (36%)
5 (36%)
0
19 (76%)
6 (24%)
72.6 ± 7.2
10 (40%)
12 (48%)
3 (12%)
8.2 ± 3.7
9 (36%)
12 (48%)
3 (12%)
1 (4%)
12 (100%)
0
0
0
0
9 (64%)
4 (29%)
1 (7%)
0
0
9 (36%)
4 (16%)
5 (20%)
3 (12%)
4 (16%)
Data are shown as No. (%) of subjects or mean ± standard deviation.
All patients were cognitively intact.
was incorporated in the instructions to testers. The resultant
MoCA-P version finalised after the pilot testing is shown in
the Figure.
The MoCA-P yielded a high level of internal
consistency (Cronbach’s α = 0.938). Re-test reliability was
done at a mean of 15.31 days (standard deviation [SD], 6.79
days) apart, although 4 of the 25 participants failed to return
for re-testing. The mean MoCA scores were 16.14 and
16.81 for baseline and follow-up, respectively, with a mean
change of -0.76 (SD, 2.26) points. The inter-rater and intrarater reliability were 0.887 (p ≤ 0.05) and 0.969 (p ≤ 0.05),
respectively. The MoCA-P correlated negatively with the
Epworth Sleepiness Scale (r = –0.233) and had a positive
but low correlation with the MMSE-P (r = 0.555). This low
convergent validity could be due to the fact that, although
both tests are measures of cognition and should be highly
correlated, the MMSE-P is limited in measures of executive
function, which are found in the MoCA-P.
Discussion
At least some degree of familiarity of participants with
test items is essential for a test to be valid. In the Korean
version of the MoCA, ‘velvet’ and ‘daisy’ were changed
to ‘silk’ and ‘azalea’, respectively, because the original
items were unfamiliar to Korean elderly people.17 In
the MoCA-P, 2 words were changed in the memory list
because they have no Filipino translation. Silk (‘seda’ in
Filipino) was used to replace velvet because it is a familiar
East Asian Arch Psychiatry 2013, Vol 23, No.3
fabric used for religious draperies and daisy was replaced
by rose (‘rosas’).
The elderly participants employed a different cognitive
approach to western populations when determining the
relationship of 2 seemingly obtuse objects as evidenced by
the answers to the similarity of bicycle and train or orange
and banana. Certain responses are therefore rated as correct
in the MoCA-P, even if different from the original version.
This issue is of particular importance in this instance when
a response can only be rated as right or wrong, unlike in
protocols where responses are graded in a 3-point scale
from best to inappropriate answers. The same is true of the
rating for the cube performance, which can only be scored
as either right or wrong, whereas in other protocols such
as the Alzheimer’s Disease Assessment Scale–Cognitive
Subscale,22 the answers are rated with respect to lines, face
orientation, parallelism, and dimensionality. Subjectivity
was therefore observed in the testers when rating these tests,
including the simple clock drawing where the tester could
be lenient or strict.
The need for modification of the test items and
instructions in the MoCA-P supports the recommendation
of the International Working Group for the Harmonization
of Dementia Drug Guidelines that test instruments should
be validated in the population where the tests will be used,
particularly in populations for whom language and cultural
experiences differ from those of the West.23 Valid assessment
of elderly Filipino patients can now be done using the
MoCA-P, and since the MoCA has also been validated in
83
JC Dominguez, MGS Orquiza, JR Soriano, et al
Figure. Filipino version of the Montreal Cognitive Assessment.
other Asian countries,16,17 it can be used in cross-cultural
studies of dementia in Asia.
This study has some limitations. Firstly, in adapting
an existing instrument, conclusions based on concepts in
the original instrument’s source culture may be heightened
despite differences or absence of these concepts in the
Filipino culture, as was evident in the abstraction subtest.
Thus, an implicit limitation in this adaptation is the
restriction in discovering or identifying patterns unique
84
to the Filipino elderly in exchange for content validity.
Secondly, the subjectivity in rating responses justifies the
development of an instruction manual to standardise test
administration, rating, and interpretation.
Conclusion
Contextual translation and pilot testing yielded several
modifications in the adaptation of the MoCA for use in the
East Asian Arch Psychiatry 2013, Vol 23, No.3
Montreal Cognitive Assessment for Elderly Filipino Patients
Philippines. Pre-testing study showed that the MoCA-P is
a reliable instrument for use in the Filipino elderly. Due
to the variability of responses that can be considered as
correct by testers and subjectivity in rating responses, a
manual of instructions must be developed to standardise
test administration, rating, and interpretation. Further
diagnostic validation of the MoCA-P to establish cutoff
scores that would discriminate elderly individuals with
normal cognition from those with dementia is needed to
establish the clinical utility of the test.
Acknowledgement
This study would not have been possible without the
support of the St. Luke’s Medical Center Research and
Biotechnology Division, the Philippine Council for Health
Related Diseases of the Philippine Department of Science
and Technology, and Prof. Ziad Nasreddine who granted
permission to adapt the MoCA.
Declaration
This study was supported by St. Luke’s Medical Center
and the Philippine Council for Health and Research
Development, Philippine Department of Science and
Technology. The authors declared that they have no
disclosures to make.
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