Floor and ceiling effects on the Montreal Cognitive Assessment in patients with Parkinson’s disease in Brazil

Koshimoto, Brenda Hanae Bentes; Brandão, Pedro Renato de Paula; Borges, Vanderci; Ferraz, Henrique Ballalai; Schumacher-Schuh, Artur Francisco; Rieder, Carlos Roberto de Mello; Olchik, Maira Rozenfeld; Mata, Ignacio Fernandez; Tumas, Vitor; Santos-Lobato, Bruno Lopes

doi:10.1590/1980-5764-DN-2023-0022

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Dementia & Neuropsychologia

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Original Article • Dement. neuropsychol. 17 • 2023 • https://doi.org/10.1590/1980-5764-DN-2023-0022 copy

Floor and ceiling effects on the Montreal Cognitive Assessment in patients with Parkinson’s disease in Brazil

Efeitos solo e teto na Avaliação Cognitiva de Montreal em pacientes com doença de Parkinson no Brasil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Parkinson’s disease (PD) is a common neurodegenerative disease associated with cognitive impairment. The Montreal Cognitive Assessment (MoCA) has been used as a recommended global cognition scale for patients with PD, but there are some concerns about its application, partially due to the floor and ceiling effects.

Objective:

To explore the floor and ceiling effects on the MoCA in patients with PD in Brazil.

Methods:

Cross-sectional study with data from patients with PD from five Brazilian Movement Disorders Clinics, excluding individuals with a possible diagnosis of dementia. We analyzed the total score of the MoCA, as well as its seven cognitive domains. The floor and ceiling effects were evaluated for the total MoCA score and domains. Multivariate analyses were performed to detect factors associated with floor and ceiling effects.

Results:

We evaluated data from 366 patients with PD and approximately 19% of individuals had less than five years of education. For the total MoCA score, there was no floor or ceiling effect. There was a floor effect in the abstraction and delayed memory recall domains in 20% of our sample. The ceiling effect was demonstrated in all domains (80.8% more common in naming and 89% orientation), except delayed recall. Education was the main factor associated with the floor and ceiling effects, independent of region, sex, age at evaluation, and disease duration.

Conclusion:

The floor and ceiling effects are present in specific domains of the MoCA in Brazil, with a strong impact on education. Further adaptations of the MoCA structure for underrepresented populations may reduce these negative effects.

Keywords:
Mental Status and Dementia Tests; Parkinson Disease; Data Accuracy; Brazil

Variable		Total (n=366)	Belém (n=90)	Ribeirão Preto (n=58)	São Paulo (n=74)	Porto Alegre (n=83)	Brasília (n=61)	p-value
Male sex, % (n)		59.3 (217)	62.2 (56)	58.6 (34)	67.6 (50)	36.1 (30)	77.0 (47)	<0.001 ^* * Pearson’s chi-square test comparing frequencies between patients from Brazilian centers
Age at evaluation^† † Values in median (interquartile range)		59 (52–67)	57 (50–71)	60 (50–71)	58 (52–66)	60 (52–67)	64 (52–71)	0.12^‡ ‡ Kruskal-Wallis test comparing medians between patients from Brazilian centers. Bold numbers indicate p<0.05.
PD duration^† † Values in median (interquartile range)		7 (4–11)	5 (3–10)	7 (3–13)	7 (5–11)	11 (6–14)	3 (2–6)	<0.001 ^‡ ‡ Kruskal-Wallis test comparing medians between patients from Brazilian centers. Bold numbers indicate p<0.05.
Hoehn & Yahr stage. % (n)	1	12 (44)	5.1 (5)	8.3 (5)	2.5 (2)	3.44 (3)	47.8 (29)	<0.001 ^* * Pearson’s chi-square test comparing frequencies between patients from Brazilian centers
	2	67.4 (247)	78.2 (70)	77.8 (45)	71.6 (53)	56 (47)	52.1 (32)
	3	13.6 (50)	9 (8)	8.3 (5)	23.5 (17)	24.5 (20)	0 (0)
	4	5.73 (21)	7.1 (6)	5.6 (3)	1.2 (1)	12.9 (11)	0 (0)
	5	1 (4)	0.6 (1)	0 (0)	1.2 (1)	3.01 (2)	0 (0)
Years of education^† † Values in median (interquartile range)		11 (6–13)	11 (8–11)	8 (4–13)	8 (4–11)	8 (5–12)	16 (11–18)	<0.001 ^‡ ‡ Kruskal-Wallis test comparing medians between patients from Brazilian centers. Bold numbers indicate p<0.05.
Education level, % (n)	No formal education	3 (11)	2.2 (2)	0 (0)	5.4 (4)	6 (5)	0 (0)	<0.001 ^* * Pearson’s chi-square test comparing frequencies between patients from Brazilian centers
	1–4 years	16.7 (61)	7.8 (7)	32.8 (19)	31.1 (23)	12 (10)	3.3 (2)
	5–8 years	22.4 (82)	20 (18)	22.4 (13)	23 (17)	37.3 (31)	4.9 (3)
	9–11 years	27.3 (100)	54.4 (49)	17.2 (10)	20.3 (15)	19.3 (16)	16.4 (10)
	≥12 years	30.6 (112)	15.6 (14)	27.6 (16)	20.3 (15)	25.3 (21)	75.4 (46)
MoCA total score^b	Median (IQR)	24 (21–26)	23 (21–26)	23 (21–26)	23 (20–26)	24 (21–26)	26 (24–27)	<0.001 ^‡ ‡ Kruskal-Wallis test comparing medians between patients from Brazilian centers. Bold numbers indicate p<0.05.
MoCA total score^b	Minimum-Maximum	11–30	13–30	18–30	13–30	11–30	20–30

Variable		Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	p-value^* * Analysis of variance comparing domain scores between education levels: 0y, 1–4y, 5–8y, 9–11y, and 12+y indicate the education level in years. Bold numbers indicate p<0.05.
Belém (n=90)		0y (n=2)		1–4y (n=7)		5–8y (n=18)		9–11y (n=49)		12+y (n=14)
	Visual-spatial/executive functions	1.00	1.41	2.28	1.38	2.83	1.46	3.67	1.32	4.07	0.82	0.001
	Naming	1.33	1.15	2.28	0.75	2.44	0.70	2.77	0.42	2.85	0.53	0.012
	Attention	1.50	0.70	4.42	1.39	3.88	1.13	4.87	1.18	5.21	0.57	<0.001
	Language	0.00	0.00	1.71	0.75	1.44	0.98	2.12	0.90	2.14	0.94	0.003
	Abstraction	0.00	0.00	1.00	0.81	0.83	0.78	1.22	0.77	1.71	0.46	0.003
	Delayed recall	2.00	0.00	0.57	1.51	1.22	1.11	1.91	1.65	3.14	1.74	0.003
	Orientation	5.00	1.41	5.71	0.48	5.77	0.42	5.91	0.27	5.92	0.26	0.007
	MoCA Total Score	13.50	0.70	19.85	3.28	20.33	2.78	24.40	3.07	25.92	2.49	<0.001
Ribeirão Preto (n=58)		0y (n=0)		1–4y (n=19)		5–8y (n=13)		9–11y (n=10)		12+y (n=16)
	Visual-spatial/executive functions	NA	NA	2.84	1.46	2.69	1.37	3.20	1.03	4.12	1.02	0.012
	Naming	NA	NA	2.89	0.31	2.46	0.66	2.90	0.31	2.87	0.34	0.023
	Attention	NA	NA	4.31	1.52	4.76	1.09	4.80	0.91	5.37	0.80	0.080
	Language	NA	NA	1.68	0.82	1.69	0.94	1.70	1.15	2.37	0.61	0.070
	Abstraction	NA	NA	0.84	0.76	0.76	0.92	1.20	0.91	1.75	0.44	0.002
	Delayed recall	NA	NA	2.42	1.38	2.15	1.51	2.90	1.19	3.12	1.36	0.230
	Orientation	NA	NA	5.84	0.50	5.92	0.27	5.46	1.24	5.95	0.21	0.440
	MoCA Total Score	NA	NA	21.84	3.18	21.46	3.35	23.70	2.49	25.68	2.21	<0.001
São Paulo (n=74)		0y (n=4)		1–4y (n=23)		5–8y (n=17)		9–11y (n=15)		12+y (n=15)
	Visual-spatial/executive functions	1.25	0.95	2.08	1.47	2.94	1.19	3.93	1.16	4.26	1.22	<0.001
	Naming	2.75	0.50	2.82	0.38	2.82	0.39	2.86	0.35	3.00	0.00	0.520
	Attention	2.75	1.50	3.95	1.49	4.88	0.85	5.40	0.63	5.53	0.83	<0.001
	Language	0.75	0.50	1.82	0.75	2.17	1.07	1.93	1.03	2.40	0.94	0.014
	Abstraction	0.50	1.00	0.65	0.64	1.17	0.88	1.80	0.41	1.73	0.70	<0.001
	Delayed recall	0.00	0.00	1.82	1.61	2.11	1.57	1.93	1.65	3.06	1.33	0.005
	Orientation	4.75	2.50	5.82	0.38	5.88	0.33	5.86	0.51	6.00	0.00	0.017
	MoCA Total Score	13.75	0.95	20.00	2.74	23.00	2.78	24.73	3.03	26.13	2.64	<0.001
Porto Alegre (n=83)		0y (n=5)		1–4y (n=10)		5–8y (n=31)		9–11y (n=16)		12+y (n=21)
	Visual-spatial/executive functions	1.80	2.04	1.70	1.88	2.61	1.66	3.12	1.58	3.76	1.22	0.007
	Naming	2.60	0.64	2.80	0.42	2.70	0.58	2.83	0.46	2.90	0.30	0.160
	Attention	2.80	1.50	3.80	1.22	4.67	1.01	4.87	1.25	4.61	1.24	0.006
	Language	1.40	0.54	1.80	0.42	2.09	0.65	2.31	0.70	2.33	0.73	0.023
	Abstraction	0.20	0.44	1.00	0.47	1.22	0.71	1.68	0.47	1.47	0.67	<0.001
	Delayed recall	0.60	0.54	2.10	1.85	1.61	1.58	2.68	1.16	3.14	1.52	<0.001
	Orientation	5.00	1.41	5.80	0.42	5.83	0.45	5.87	0.51	5.90	0.30	0.010
	MoCA Total Score	16.00	6.08	20.90	2.46	22.70	3.44	25.50	3.07	25.66	3.05	<0.001
Brasília (n=61)		0y (n = 0)		1–4y (n = 2)		5–8y (n = 3)		9–11y (n = 10)		12+y (n = 16)
	Visual-spatial/executive functions	NA	NA	4.00	1.41	3.66	2.30	3.20	1.39	4.36	0.99	0.037
	Naming	NA	NA	2.00	0.00	2.66	0.57	2.60	0.51	2.93	0.24	<0.001
	Attention	NA	NA	5.00	0.00	4.33	0.98	5.10	0.87	5.32	0.94	0.330
	Language	NA	NA	2.50	0.70	2.00	1.00	1.70	0.94	2.19	0.80	0.340
	Abstraction	NA	NA	1.50	0.70	1.33	0.57	1.40	0.69	1.78	0.51	0.140
	Delayed recall	NA	NA	1.50	2.12	3.00	1.73	2.70	1.94	3.30	1.22	0.230
	Orientation	NA	NA	5.50	0.70	6.00	0.00	5.90	0.31	5.95	0.20	0.070
	MoCA Total Score	NA	NA	25.00	4.24	24.00	4.00	23.60	2.91	26.10	2.14	0.008

Domains/Clinical variables		Floor effect				Ceiling effect
Domains/Clinical variables		B	aOR	95%CI	p-value	B	aOR	95%CI	p-value
Visual-spatial/executive functions	Female sex	0.223	1.25	0.47–3.29	0.65	0.149	1.16	0.62–2.14	0.63
	Age at evaluation	-0.006	0.99	0.94–1.04	0.82	-0.007	0.99	0.96–1.02	0.63
	Disease duration	0.05	1.05	0.97–1.14	0.16	-0.009	0.99	0.93–1.05	0.75
	Years of education	-0.222	0.80	0.70–0.91	0.001	0.190	1.20	1.12–1.29	<0.0001
Naming	Female sex	37.8	0.00	0.00–0.00	0.99	-0.266	0.76	0.41–1.42	0.39
	Age at evaluation	-0.954	0.38	0.00–0.00	0.98	-0.007	0.99	0.96–1.02	0.65
	Disease duration	-12.54	0.00	0.00–0.00	0.97	-0.036	0.96	0.91–1.01	0.20
	Years of education	-6.249	0.00	0.00–0.00	0.97	0.147	1.15	1.07–1.25	<0.0001
Attention	Female sex	33.823	0.00	0.00–0.00	0.84	-0.031	0.97	0.56–1.65	0.91
	Age at evaluation	-0.331	0.71	0.31–1.66	0.43	-0.001	0.99	0.97–1.02	0.96
	Disease duration	0.766	2.15	0.81–5.69	0.12	0.005	1.00	0.95–1.05	0.83
	Years of education	-1.933	0.14	0.01–2.60	0.19	0.126	1.13	1.07–1.20	<0.0001
Language	Female sex	0.059	1.06	0.37–2.99	0.91	-0.053	0.94	0.55–1.61	0.84
	Age at evaluation	-0.021	0.97	0.93–1.02	0.38	-0.017	0.98	0.95–1.00	0.17
	Disease duration	-0.003	0.99	0.91–1.09	0.95	-0.018	0.98	0.93–1.03	0.48
	Years of education	-0.151	0.86	0.75–0.97	0.022	0.108	1.11	1.05–1.17	<0.0001
Abstraction	Female sex	-0.862	0.42	0.21–0.81	0.01	0.355	1.42	0.82–2.45	0.20
	Age at evaluation	0.022	1.02	0.99–1.05	0.15	-0.013	0.98	0.96–1.01	0.31
	Disease duration	0.036	1.03	0.98–1.09	0.19	-0.023	0.97	0.92–1.02	0.38
	Years of education	-0.25	0.77	0.71–0.84	<0.0001	0.241	1.27	1.18–1.36	<0.0001
Delayed memory recall	Female sex	-0.342	0.71	0.38–1.31	0.27	0.187	1.20	0.52–2.78	0.72
	Age at evaluation	-0.008	0.99	0.96–1.02	0.61	0.007	1.00	0.96–1.04	0.66
	Disease duration	0.019	1.01	0.96–1.07	0.50	-0.007	0.99	0.91–1.07	0.87
	Years of education	-0.198	0.82	0.75–0.88	<0.0001	0.111	1.11	1.02–1.21	0.008
Orientation	Female sex	-0.342	0.71	0.38–1.31	0.27	-0.814	0.44	0.20–0.95	0.03
	Age at evaluation	-0.008	0.99	0.96–1.02	0.61	-0.017	0.98	0.94–1.02	0.37
	Disease duration	0.019	1.01	0.96–1.07	0.50	-0.048	0.95	0.89–1.01	0.15
	Years of education	-0.198	0.82	0.75–0.88	<0.0001	0.132	1.14	1.04–1.25	0.005

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[1] Correspondence: Bruno Lopes Santos-Lobato; Email: bruls4@ufpa.br.