Is a Montreal Cognitive Assessment (MoCA) score of 24 considered normal for an older adult?

MoCA Score of 24: Not Definitively Normal for Older Adults

A MoCA score of 24 should not be automatically considered normal in an older adult, even accounting for age, as this score falls in a gray zone that requires further clinical evaluation including functional assessment and informant input to distinguish between normal cognition and mild cognitive impairment.

Understanding MoCA Score Interpretation

The interpretation of a MoCA score of 24 is more nuanced than simply labeling it "normal" or "abnormal":

Current Evidence on Cutoff Scores

• The original MoCA cutoff of ≤26 for MCI has been revised downward based on accumulating evidence showing high false-positive rates 1
• Recent meta-analysis supports 24 as the optimal cutoff for screening suspected cognitive impairment, with good diagnostic accuracy (AUC 0.84) for detecting amnestic MCI 2
• A score of 24 represents a diagnostic gray zone where classification is uncertain—neither clearly normal nor clearly impaired 3

Why 24 Is Problematic as "Normal"

The 2020 Canadian Consensus Conference guidelines explicitly state that the MoCA is more sensitive to MCI than the MMSE and is recommended when mild cognitive impairment is suspected, particularly when MMSE scores are in the "normal" range (24+ out of 30) 1. This indicates that a MoCA score of 24 itself warrants concern.

Large population studies demonstrate significant variability:

• Cognitively healthy Norwegian adults (excluding those with dementia, MCI, stroke, or depression) showed mean MoCA scores ranging from 22-27 depending on age, education, and sex 4
• The Framingham Heart Study found average MoCA scores of 24.69 in cognitively unimpaired middle-aged and older adults, with those over 60 scoring below 23 on average 5

Clinical Approach to a MoCA Score of 24

Do not stop at the MoCA score alone. The guidelines are unequivocal that diagnosis requires a multi-dimensional assessment:

Essential Next Steps (Grade 1A-1B Recommendations)

1. Obtain corroborative informant history about changes in cognition, function, and behavior 1

   • Use structured tools: AD8, IQCODE, or ECog
   • Informant report is essential due to variability in patient insight 1

2. Assess functional status objectively with patient and family member 1

   • Use Pfeffer FAQ or Disability Assessment for Dementia (DAD)
   • The distinction between MCI and dementia hinges on functional impairment 1

3. Screen for behavioral/mood changes 1

   • Use NPI-Q, MBI-C, or PHQ-9
   • Depression, anxiety, and other psychiatric conditions can affect MoCA performance

4. Consider demographic factors that influence MoCA performance:

   • Age (scores decline with advancing age) 4, 5
   • Education (scores increase with higher education) 6, 7, 4
   • Sex (women tend to score slightly higher) 4

Diagnostic Algorithm

If MoCA = 24:

• Positive informant report of decline + functional impairment → Likely MCI or early dementia; proceed with full diagnostic workup
• Positive informant report + preserved function → Likely MCI; annual follow-up recommended 1
• Negative informant report + no functional concerns → Reassurance with follow-up if deterioration noted 1
• Uncertain or conflicting information → Consider neuropsychological testing for detailed cognitive domain assessment 8

Critical Pitfalls to Avoid

1. Do not diagnose or exclude cognitive impairment based on MoCA score alone 1—combining cognitive tests with functional screens and informant reports improves diagnostic accuracy (Grade 1A) 1

2. Do not assume age alone explains the score—while MoCA scores decline with age in healthy populations, a score of 24 in an older adult still warrants investigation, particularly if there are subjective concerns 4, 5

3. Do not overlook reversible causes—ensure appropriate medical workup for conditions that can affect cognition (depression, sleep apnea, metabolic issues, medications) 1

4. Do not use a single assessment timepoint—longitudinal serial assessments improve diagnostic accuracy 1

Bottom Line for Clinical Practice

A MoCA score of 24 in an older adult is a red flag requiring further evaluation, not a reassuring "normal" result. The score sits at or near the optimal cutoff for detecting MCI across multiple validation studies 7, 9, 2. Prioritize functional assessment and informant input over the numerical score alone to determine whether this represents normal aging, MCI, or early dementia—this approach directly impacts morbidity through early intervention opportunities and quality of life through appropriate care planning.