MoCA Tests
A crash course in cognitive decline (and remapping) as we celebrate the holidays.
On Friday, I went with my dad to what has become his now-annual neurology assessment. This was only his second one since moving into our new house after living a few years of a somewhat chaotic life in Assisted Living with my mother, a season marked by temporal amnesia, vascular dementia, and a caregiver breakdown as the pandemic raged and isolation suffocated them both. We had moved him into care because we needed help; now I was trying to build something that looked more like stability.
I had requested that he see a neurologist at the clinic near our home so we could finally have some steady, predictable care instead of the revolving door of primary care providers at the assisted living place. Sure, seeing someone once a year isn’t exactly a deep therapeutic relationship, but at this point, an annual check-in is what’s medically required, and he made it very clear that I am welcome to contact him if anything new comes up, which matters a lot to a primary caregiver.
Last year, I had been riding high after getting Dad’s Montreal Cognitive Assessment (MoCA) results. His first time through, he scored 25 out of 30; a score of 26 and above is generally considered “normal,” with 18–25 often interpreted as mild cognitive impairment and lower scores suggesting more significant impairment. We already knew he had gotten better since moving in with us, but seeing that number felt like external validation of what I was seeing every day. I know a score is just one input and one data point, but it felt pretty legit.
Going into this year’s appointment, I wondered if he might tip over into that “normal” range because he has been doing so well. With the routine and quiet of our home—me as his primary caregiver—we have crafted a pretty fine life. He is able to do things that, in those terrifying early months of cognitive free fall, I honestly did not think he would ever get back.
I listened along as the woman ran him through the test. She asked him to draw a clock with a certain time, to draw a box, to list numbers in order—but backwards, to remember five words she read aloud, to say what day and date it was, where he was, what certain things had in common, and a handful of other seemingly random tasks. I cringed a bit when I could tell he did not quite hear the words to remember correctly. Then I really cringed when he got the day, date, and year wrong—though, if we are being fair, I did not know the date either.
When the neurologist came in, he asked how things were; Dad assured him they are good. Then he asked if we would be okay with Dad starting a medication intended to slow memory loss, and we were fine with that. The reason he gave was that Dad’s MoCA score this year was 22, a drop from 25. Where I had been quietly hoping he had gone up, he had actually gone down in a way that looked significant on paper.
I told him how surprised I was, because having real conversations with doctors feels non-negotiable to me. They are our partners in health, not people on pedestals to be listened to but never questioned. He was genuinely interested in what I had to say. “It’s an imperfect test, but it’s all we have,” he said. He was surprised—but not shocked—when I described how much better Dad has been this year, how he is reading, cooking, following routines, engaging with life. He said he had already heard from a few people that week that their loved ones’ scores were low, yet they were home baking cookies and making Christmas food: behaviors that suggest intact or at least functional executive skills, which do not neatly match a low screening score. That mismatch between test and lived life is exactly where my caregiver brain lives.
I told him all about Dad’s daily patterns and how his new hearing aids have helped immensely with communication and engagement. The doctor agreed with my observations and with my point that, in this case, the qualitative picture should carry at least as much weight as the quantitative data. He encouraged me to come along next year as well so there is continuity in the story that gets told in that exam room. Oh, I will.
It felt validating to hear, out loud, that the MoCA is not a perfect test. But we also agreed that there was no harm in trying the new medication; if it helps, it helps, and if it does not, we will know that, too. Dad just said, “So, I’m good for another year?” Yes. He is. That satisfied him and we were out of there.
All the way home, I felt the cascade: denial, fear, anger. Is this the best we have? How can a tool be this limited and still carry this much weight? It felt like one of those BuzzFeed quizzes that tell you which Disney Princess you are. So few questions, so many implications. Then I replayed which questions he got wrong and which he nailed. He actually did a great job. I promised myself I would look the test up when we got home, to see how the scoring really works, because I was pretty sure that those orientation questions—day, date, location—were worth more than they felt in the room.
My body was tense; my blood pressure felt like it had climbed; I was hot and unsettled. So I did what I do: I used my self-regulation skills and got us home in about 13 minutes, and in those 13 minutes I breathed, grounded, and calmed my nervous system enough to get curious instead of just angry. When I finally sat down and read through the MoCA, I found out I was right: some of those “simple” questions carry multiple points, so a missed date or misheard word can have an outsized effect on the total score. And I recognized that I personalized the results. That I felt like I had dropped in points or failed him.
Here is the deal. Many of us are already caring for aging parents and relatives, or will be soon. Many of us see them in December. This is exactly when we need to remember that we are neuro-biopsychosocial people—brains, bodies, minds, and relationships all woven together.
Let’s break it down.
What the MoCA Test Is
As much as I wish it were a chocolatey latte, the MoCA—Montreal Cognitive Assessment—is a brief screening tool designed to detect mild cognitive impairment and early dementia by sampling a range of mental skills in about 10–15 minutes. It is not meant to be a full neuropsychological evaluation but a quick snapshot that helps clinicians decide whether more in-depth testing is needed.
The test covers multiple domains that often change early in dementia, including attention, memory, language, visuospatial skills, executive functioning, and orientation to time and place. Because it compresses a lot into 30 points, even a handful of missed items can look dramatic on the score sheet while not fully capturing how a person moves through their everyday life.
What Those 30 Points Are
The MoCA is scored out of 30 points, each attached to specific tasks that look deceptively simple. Some questions carry more weight than others, especially orientation and delayed recall.
Here is the general structure of those points:
Visuospatial and executive skills: copying a cube, drawing a clock with a specified time, connecting alternating numbers and letters.
Naming: identifying pictures of three animals.
Attention: repeating number sequences, tapping on certain letters, subtracting by sevens from a starting number.
Language: repeating sentences and generating as many words as possible that start with a specific letter.
Abstraction: explaining how two items (like a train and a bicycle) are alike.
Delayed recall: remembering a list of five words after a brief delay.
Orientation: stating the date, month, year, day of the week, place, and city.
Many items are scored all-or-nothing, and orientation can account for several points by itself. That means mishearing a word, not catching the instructions clearly because of hearing loss, or getting the date wrong during the blur of holiday season can pull the number down in a way that does not necessarily match functional reality.
What MoCA Scores Mean (and Don’t)
In general, a MoCA score of 26–30 is considered within the normal range, while 18–25 often suggests mild cognitive impairment and lower scores indicate more substantial impairment, depending on education and other factors. Clinicians also sometimes add one point for people with fewer years of formal education, which can shift how “borderline” scores are interpreted.
But there are clear limitations: one short test on one day cannot fully capture fluctuations due to fatigue, pain, anxiety, hearing or vision issues, cultural background, or how familiar someone is with testing situations. A person can score lower yet still cook, manage familiar routines, and participate meaningfully in family life because real-world functioning draws on well-worn neural pathways, habits, emotional memory, and environmental supports that the MoCA only brushes against.
What Neuro-Biopsychosocial Means for Dementia
The biopsychosocial model describes how biological, psychological, and social factors together shape health and illness—your brain and body, your thoughts and emotions, and your relationships and environment are all part of one system. The neuro-biopsychosocial update makes the “neuro” piece explicit, emphasizing that the brain’s structure and function, and its capacity for change, sit alongside those other layers.
In dementia, the biological level includes vascular changes, neurodegeneration, and sensory issues like hearing loss; the psychological level includes mood, coping style, and beliefs; and the social level includes caregiving, routines, housing, and financial and cultural context. The MoCA mainly taps the “neuro” and some “psycho” pieces, but does not fully account for how a calmer home, predictable routines, loving relationships, and assistive tools can support function even when test scores dip.
Where MoCA and Dementia Care Intersect
In early and mid-stage dementia, tests like the MoCA can help track cognitive changes over time and guide decisions about medications, safety, and supports. The problem arises when the number is treated as the whole story rather than one chapter in a much bigger book.
Viewing results through a neuro-biopsychosocial lens means asking questions like: Did they sleep last night? Did they hear the instructions? Are they anxious in medical settings? Are they more themselves when they are home in their favorite chair, cooking a familiar recipe, with fewer distractions? When families and clinicians bring these layers together, decisions about medications, services, and expectations get more humane and more accurate.
How Remapping Neural Pathways Affects Dementia
The adult brain remains capable of neuroplasticity—the ability to form and reorganize connections—well into older age, even in the presence of early dementia pathology. Experiences, learning, and repeated practice can build “cognitive reserve,” extra neural routes the brain can use to maintain function despite underlying damage. This is incredibly comforting to know.
For people on a dementia trajectory, activities that engage attention, planning, movement, and emotion—like cooking familiar recipes, music, conversation, or crafts—can help strengthen remaining pathways and support compensation. While these practices do not cure dementia, they can delay functional decline, reinforce identity, and make daily life feel more coherent and dignified.
Intentional remapping through structured routines and meaningful activities can:
Support preserved abilities, which feels empowering and reduces frustration.
Reduce behavioral symptoms by lowering anxiety and providing predictable anchors in the day.
Enhance mood and engagement by tapping into long-term memories and sensory cues, especially around music, food, and holiday traditions.
When the environment is calmer and more supportive, people with dementia often appear “better” than their test scores suggest, because the world around them is scaffolding their brain’s remaining strengths.
How this Helps the Helpers
For caregivers and family, this perspective can shift the focus from “How do we fix the score?” to “How do we build the best possible life with the brain they have today?” A neuro-biopsychosocial frame validates the emotional labor of caregiving and the real impact of things like routines, communication strategies, and sensory adjustments.
It also protects caregivers from over-identifying with one number—something I grappled with the entire drive home from the seeing the doctor. Understanding that the MoCA is a useful but blunt instrument makes it easier to trust what we see with our own eyes: the laughter, the cookies, the Christmas list, the way they still sing along to carols in perfect time. (Okay, maybe not perfect, but he killed it at our Christmas Sing-Along the other night.) That qualitative story is not “soft”; it is data, too.
When the MoCA Idea Does Help
Even though this whole story is about not over-identifying with a single MoCA score, there is another side to this: the spirit of the MoCA can be a powerful ally if you are trying to get help for someone you love. The test itself is just structured curiosity—simple questions that sample memory, attention, language, and orientation in a focused way.
If you are already concerned about a loved one, you do not need to formally “test” them to justify getting help; your observations, gut feelings, and day-to-day experiences are valid data. But if you feel stuck explaining your concerns, it can be helpful to gently notice MoCA-like things: Are they consistently mixing up the date, year, or season? Are they struggling to follow multi-step instructions, like a simple recipe or a short list? Are they losing the thread in conversations more than before, or having trouble finding basic words? Using those kinds of examples—very similar to what shows up on the MoCA—can make it easier to talk to a doctor, to document patterns over time, and to advocate for an evaluation.
You can even “informally MoCA” in your own mind by watching how they handle:
Orientation: Do they know where they are and roughly what day/month it is?
Attention: Can they follow along if you read them a short list of items or give them a two-step direction?
Executive functioning: Can they sequence tasks like getting dressed, making coffee, or paying a bill without getting lost midstream?
You do not need to turn your relationship into a quiz show, and you do not have to sit them down with a clipboard. Small, compassionate observations in everyday life are enough. If those observations confirm what your heart already knows—that they need more support—that is reason enough to call the clinic, ask for a cognitive screening, or request a referral to a neurologist or memory clinic. The goal is not to chase a number, but to use the idea of structured questions to help you be heard and to get your person the care they deserve.
How ‘Even If’ Isn’t the End
Even if his score had dropped and I felt, in my bones, that it was a legitimate reflection of some decline, it still would not be a Chicken Little moment. The sky is not falling; it is shifting, and that is different. A lower score would still be one data point among many: sleep, mood, hearing, routines, engagement, lab work, and the thousand tiny ways he shows up in daily life. Dementia is a long, uneven road with plateaus, dips, and surprise bright spots, not a straight cliff you fall off in one visit. A change in numbers might mean we adjust supports, tweak medications, or re-think expectations, but it does not erase the gains he has made, the skills he still has, or the relationship we are actively living in right now.
How To Navigate the Holidays with Cognitive Changes
Holidays can be beautiful and brutal at the same time when dementia is in the mix. A few evidence-informed principles can make a big difference:
Keep routines as familiar as possible: mealtimes, wake/sleep, medications, and daily rhythms. (These might be iffy, I have to admit. I’m not sure how it’ll go this week. We might not be able to avoid messing with mealtimes and daily rhythms, but we’ll be able to manage the rest of these a bit better.)
Simplify gatherings: fewer people at once, shorter visits, quieter spaces, and an easy “escape plan”, like a bedroom, a quiet corner, a short walk. (I’ll have his Grey’s Anatomy ready to go for whenever he wants to escape to his TV area.)
Use long-term memory: familiar recipes, music, decorations, and rituals can be soothing and anchor orientation. (I actually asked him what we should have for our meal, so he’ll be really happy to see those dishes…even if he doesn’t remember he chose them.)
Prepare guests: explain in advance what to expect and how best to interact—gentle introductions, not quizzing their memory, but following their lead.
Watch sensory load: dim any flashing lights, lower background noise, avoid overwhelming smells and too many overlapping conversations. (I’ve noticed him just check out in conversations where too many people are talking. That’s when I offer Grey’s. He’s also gotten pretty good at self-regulating by deciding when it’s time to be alone. See? How great is that? Amazing. He’s growing boundaries with his neural pathways!)
Build in rest and recovery time for everyone, including us; schedule breaks, tag-team caregiving, and give ourselves permission to step away.
Most importantly, let the person’s current capacity—not the ghost of who they used to be, and not a MoCA score—set the pace. Presence, flexibility, and a bit of creative remapping can make this season kinder for their brain and gentler on ours.