A MoCA score between 26 and 30 is considered normal, while scores of 18 to 25 suggest mild cognitive impairment, scores of 10 to 17 indicate moderate impairment consistent with Alzheimer’s disease, and scores below 10 point to severe cognitive decline. Those numbers matter because the Montreal Cognitive Assessment has become one of the most widely used screening tools in dementia care, and understanding where a score falls on that spectrum can shape everything from treatment planning to family decision-making. For example, a person who scores 22 on the MoCA falls squarely in the mild cognitive impairment range, and research shows that certain memory sub-scores within that result can predict whether they will progress to Alzheimer’s dementia within 18 months.
But a single score only tells part of the story. How quickly scores change over time, which cognitive domains are most affected, and how the MoCA compares to older screening tools like the MMSE all factor into what a diagnosis actually means for someone’s future. This guide covers the full picture: what the MoCA measures, how its scoring works, what the research says about its accuracy, how scores track with dementia progression, and what families should realistically expect at each stage of the disease.
Table of Contents
- What Does the MoCA Test Actually Measure, and How Do Scores Relate to Dementia Progression?
- How Accurate Is the MoCA at Detecting Cognitive Impairment?
- How MoCA Sub-Scores Predict Who Will Progress to Alzheimer’s Disease
- MoCA vs. MMSE — Which Test Should You Ask For?
- What Dementia Progression Actually Looks Like Over Time
- How Education Level Affects MoCA Interpretation
- What Comes After a MoCA Score — Next Steps and Emerging Approaches
- Conclusion
- Frequently Asked Questions
What Does the MoCA Test Actually Measure, and How Do Scores Relate to Dementia Progression?
The Montreal cognitive Assessment was created by Dr. Ziad Nasreddine in 1996 in Montreal, Quebec, and validated in a landmark 2005 study. It is a 30-point screening tool that takes roughly 10 minutes to administer, and the current version in clinical use is MoCA 8.3. Unlike simpler cognitive screens, the MoCA evaluates eight distinct cognitive domains: visuospatial and executive function, naming, memory, attention, language, abstraction, delayed recall, and orientation. That breadth is what makes it particularly useful for catching early cognitive decline that other tests miss. In practice, the scoring breakdown looks like this. People without cognitive impairment average a score of 27.4.
Those with mild cognitive impairment average 22.1, with scores typically ranging from 19 to 25. People diagnosed with Alzheimer’s disease average 16.2, with scores ranging from 11 to 21. A general cutoff of 18 is used clinically to separate MCI from Alzheimer’s disease, though there is meaningful overlap between the two groups. That overlap is worth noting because a person scoring 19 could fall on either side of the line depending on their education level, baseline cognitive ability, and the specific pattern of their errors across the eight domains. One important adjustment: if a person has 12 years or fewer of formal education, one point is added to their final score to account for the influence of educational background on test performance. Some studies apply a two-point adjustment for individuals with only 4 to 9 years of education. Without this correction, people with less formal schooling are more likely to be flagged for impairment they may not actually have.
How Accurate Is the MoCA at Detecting Cognitive Impairment?
The original validation study found that the MoCA had a sensitivity of 90 percent and a specificity of 87 percent for detecting mild cognitive impairment at a cutoff score below 26. For dementia specifically, a cutoff below 26 correctly identifies over 94 percent of people with dementia. Those numbers sound reassuring, but there is a significant caveat: at that same cutoff, the false-positive rate exceeds 40 percent in people without dementia. That means nearly half of cognitively healthy people who take the test could be told their score suggests impairment when it does not. This is why researchers have explored alternative cutoffs. A cutoff below 22, for instance, demonstrated 83.9 percent sensitivity and 82.9 percent specificity for discriminating dementia from non-dementia, which dramatically reduces false positives at the cost of missing some true cases.
A large meta-analysis supports a cutoff of 24 as the optimal balance for screening suspected cognitive impairment. The takeaway for families is that a single MoCA score near the borderline should never be treated as a definitive diagnosis. It is a screening tool, not a diagnostic one. A score of 24 or 25 warrants further evaluation, not panic. However, if someone scores well below 20 on the MoCA, the test’s accuracy becomes much more reliable. The further a score falls from the normal range, the less ambiguity there is. The challenge lives in the middle of the scale, where the difference between normal aging, MCI, and early dementia can be genuinely difficult to distinguish with any single assessment.
How MoCA Sub-Scores Predict Who Will Progress to Alzheimer’s Disease
One of the most clinically useful developments in MoCA research is the Memory Index Score, a sub-score derived from the delayed recall portion of the test. This score, calculated on a 15-point scale, has shown remarkable predictive power. In one study, 90.5 percent of MCI participants with a Memory Index Score below 7 out of 15 at baseline progressed to Alzheimer’s dementia within an average follow-up period of 18 months. That is a striking conversion rate and gives clinicians a much more specific tool than the overall MoCA score alone. Consider a practical example. Two patients might both score 23 on the MoCA, placing them in the MCI range.
But if one has a Memory Index Score of 5 and the other has a Memory Index Score of 11, their trajectories are likely very different. The first patient has a high probability of progressing to Alzheimer’s within a year and a half. The second may remain stable for years. This kind of granularity is why researchers have moved beyond relying on a single composite number and toward analyzing patterns within the test. The Cognitive Charts approach to the MoCA takes this a step further by allowing longitudinal tracking of cognitive trajectory over time. Rather than comparing a single score to a static cutoff, this method plots repeated MoCA scores across months or years, distinguishing between the gradual decline of healthy aging, the plateau-then-drop pattern of MCI, and the steady downward slope of progressive dementia. For families tracking a loved one’s cognitive health, asking the doctor to compare current results with previous assessments is far more informative than focusing on any one number.
MoCA vs. MMSE — Which Test Should You Ask For?
For decades, the Mini-Mental State Examination was the default cognitive screening tool in clinical settings. Many older adults and their families are more familiar with the MMSE than the MoCA. But the research is clear on which performs better for early detection: the MoCA is significantly more sensitive than the MMSE for detecting mild cognitive impairment, with sensitivity rates of 90 to 100 percent compared to just 18 to 25 percent for the MMSE. That gap is enormous. The MMSE misses the vast majority of MCI cases that the MoCA catches. The reason for this difference is structural.
The MoCA includes executive function tasks such as a shortened version of the Trail Making Test B, clock drawing, and abstraction exercises that are entirely absent from the MMSE. These tasks test the frontal lobes, which are often among the first brain regions affected in early dementia and are critically involved in planning, judgment, and problem-solving. A person in the early stages of frontotemporal dementia or vascular cognitive impairment might score perfectly normally on the MMSE while showing clear deficits on the MoCA. The tradeoff is that the MMSE is simpler to administer and may be less stressful for patients with more advanced impairment, where the MoCA’s more challenging tasks can feel overwhelming. For someone already in the moderate to severe stages of dementia, the MMSE may actually be more practical. But for screening purposes and early detection, the MoCA has demonstrated greater sensitivity, specificity, and overall diagnostic accuracy than the MMSE, particularly when scores are adjusted for education. If a doctor is still using only the MMSE, it is reasonable to ask whether the MoCA might provide a more complete picture.
What Dementia Progression Actually Looks Like Over Time
Knowing a MoCA score is one thing. Understanding what it means for day-to-day life and long-term planning is another. Dementia progression is typically described in three stages, each with its own approximate timeline. The mild stage generally lasts 2 to 4 years, during which a person may have trouble with complex tasks, forget recent events, or struggle with word-finding, but can still live independently with some support. The moderate stage is the longest, lasting 2 to 10 years, and involves increasing difficulty with daily activities, personality changes, wandering, and growing need for hands-on care. The severe stage typically lasts 1 to 3 years and involves near-total dependence, loss of verbal communication, and significant physical decline. These timelines are averages, and individual variation is substantial. A person diagnosed with Alzheimer’s disease lives an average of 4 to 8 years after diagnosis, though some live 15 to 20 years. Vascular dementia tends to have a shorter course, with an average life expectancy of about 5 years.
Dementia with Lewy bodies averages roughly 6 years. Frontotemporal dementia averages 6 to 8 years. These numbers are influenced by age at diagnosis, overall health, the presence of other medical conditions, and the quality of care received. A warning worth stating plainly: the stage labels and timelines can create a false sense of predictability. Dementia does not follow a script. Some people spend years in the mild stage and then decline rapidly. Others seem to progress steadily and then plateau for an extended period. MoCA scores can help track the general direction of change, but they cannot tell you exactly when a person will need full-time care or when they will stop recognizing family members. Planning should be based on the current level of function, not on predictions about a timeline that no one can guarantee.
How Education Level Affects MoCA Interpretation
The education adjustment built into MoCA scoring — adding one point for individuals with 12 or fewer years of formal education — is a necessary correction, but it is also an imperfect one. A person who completed 8 years of schooling in a rural area 60 years ago and a person who completed 12 years at a well-resourced suburban school had very different educational experiences, even though both fall under the same adjustment category. Some research supports adding 2 points for individuals with only 4 to 9 years of education, but this is not universally applied.
For families, the practical implication is that MoCA scores should always be interpreted in the context of a person’s background. A retired university professor scoring 24 is more concerning than a person with a sixth-grade education scoring 24 after the adjustment. Clinicians who know their patients well will factor this in, but in busy clinical settings or during hospital-based screenings, the nuance sometimes gets lost. If you believe that education level may be affecting the accuracy of a score, raise it with the care team.
What Comes After a MoCA Score — Next Steps and Emerging Approaches
A MoCA score is a starting point, not an endpoint. A score suggesting MCI or dementia should lead to comprehensive neuropsychological testing, neuroimaging, blood work to rule out reversible causes of cognitive decline such as thyroid dysfunction or vitamin B12 deficiency, and a detailed clinical history. The MoCA was designed as a screening instrument, and screening instruments are meant to identify who needs further evaluation, not to deliver final diagnoses.
Looking ahead, the Cognitive Charts approach to longitudinal MoCA tracking represents a meaningful step forward in how clinicians monitor cognitive change over time. Rather than relying on a single snapshot, repeated assessments plotted on standardized charts allow for earlier detection of abnormal decline and more personalized care planning. For families navigating a new MCI or dementia diagnosis, the most useful step is to establish a baseline MoCA score and schedule regular follow-up assessments so that the rate of change, which is often more informative than any single number, becomes visible.
Conclusion
The MoCA is a well-validated, 10-minute screening tool that evaluates eight cognitive domains and provides a 30-point score that can help distinguish between normal aging, mild cognitive impairment, and dementia. Scores of 26 to 30 are considered normal, 18 to 25 suggest MCI, 10 to 17 indicate moderate impairment, and scores below 10 reflect severe decline. The Memory Index Score, a sub-score focused on delayed recall, is particularly powerful for predicting who will progress from MCI to Alzheimer’s disease, with over 90 percent of those scoring below 7 out of 15 converting within 18 months.
But numbers on a page do not capture the full reality of living with cognitive decline. Families should use MoCA scores as one piece of a larger clinical picture that includes neuroimaging, functional assessments, and the observations of people who know the patient best. Establishing a baseline and tracking scores over time is far more valuable than fixating on a single result. If you or someone you care about has received a concerning MoCA score, the next step is not to search for certainty in the number itself but to work with a qualified clinician to understand what it means in context and what actions can support the best possible quality of life going forward.
Frequently Asked Questions
What is a normal MoCA score for a 70-year-old?
A score of 26 to 30 is considered normal regardless of age. However, research shows that cognitively healthy individuals average 27.4, and normal aging does produce subtle declines. A score of 25 in a 70-year-old without functional impairment may warrant monitoring but not alarm. The education adjustment also applies: if the person has 12 or fewer years of formal education, one point is added to the total.
Can MoCA scores improve over time?
Yes, in some cases. If cognitive impairment was caused by a treatable condition such as depression, medication side effects, sleep apnea, or a nutritional deficiency, addressing the underlying cause can lead to improved scores on retesting. However, in neurodegenerative diseases like Alzheimer’s, scores generally decline over time. Repeated exposure to the same version of the test can also produce a modest practice effect, which is why alternate MoCA versions exist.
How often should the MoCA be repeated?
There is no universal guideline, but many clinicians recommend repeating the MoCA every 6 to 12 months for individuals with MCI, or sooner if noticeable changes in function occur. The value of repeated testing lies in tracking the rate of decline rather than interpreting any single score in isolation.
Is a MoCA score of 24 cause for concern?
It depends on context. At a cutoff below 26, the false-positive rate exceeds 40 percent, meaning many cognitively normal people score in this range. A meta-analysis supports 24 as an optimal screening cutoff, so a score of 24 sits right at the boundary. Further neuropsychological testing is warranted, but a score of 24 alone does not confirm cognitive impairment.
What is the difference between the MoCA and the MMSE?
The MoCA is significantly more sensitive for detecting mild cognitive impairment, with sensitivity rates of 90 to 100 percent compared to 18 to 25 percent for the MMSE. The MoCA includes executive function tasks like trail making, clock drawing, and abstraction that are absent from the MMSE. For early detection purposes, the MoCA is the superior tool. The MMSE may still be useful for monitoring patients with more advanced dementia where the MoCA’s difficulty level becomes impractical.
Does a low MoCA score mean someone has dementia?
No. The MoCA is a screening tool, not a diagnostic instrument. A low score indicates that further evaluation is needed, which may include neuropsychological testing, brain imaging, and blood work to rule out reversible causes of cognitive decline. Factors such as fatigue, anxiety, low education, hearing loss, or language barriers can all lower scores without reflecting true cognitive impairment.
