Can someone with a Montreal Cognitive Assessment (MOCA) score of 25 engage in psychotherapy?

Psychotherapy Participation with a MoCA Score of 25

Yes, individuals with a MoCA score of 25 can effectively engage in psychotherapy, as this score indicates only very mild cognitive impairment that would not significantly impair therapeutic engagement.

Understanding MoCA Scores and Cognitive Function

A MoCA score of 25 falls just below the traditional cutoff of 26 for normal cognitive function but represents only very mild cognitive impairment:

• The Alzheimer's Association clinical practice guidelines indicate that a MoCA score of 25.5 (approximately 26) is the general cutoff for possible cognitive impairment 1
• A score of 25 suggests the person has largely intact cognitive abilities with only subtle deficits
• This level of cognitive function allows for meaningful participation in therapeutic interventions

Cognitive Requirements for Psychotherapy

For effective psychotherapy participation, patients need:

• Ability to engage in verbal communication
• Sufficient memory to recall session content
• Capacity to form a therapeutic relationship
• Basic insight into their condition

A MoCA score of 25 indicates that these fundamental abilities are largely preserved, with only minor deficits that would not significantly impair therapeutic engagement.

Evidence Supporting Psychotherapy with Mild Cognitive Impairment

• The Montreal Cognitive Assessment evaluates multiple cognitive domains including orientation, memory, language, attention, visuospatial abilities, and executive functions 2
• Individuals with MoCA scores of 25 typically maintain adequate functioning in most of these domains
• Research suggests that a MoCA cutoff of <25 (rather than <26) may be more appropriate for identifying significant cognitive impairment in some populations 3
• Cognitive behavioral therapy (CBT) is specifically recommended as a first-line treatment for various conditions even when mild cognitive issues are present 1

Adapting Psychotherapy Approaches

For patients with a MoCA score of 25, consider these adaptations:

• Session structure: Shorter, more frequent sessions may be beneficial
• Memory aids: Written summaries of sessions or audio recordings can help reinforce content
• Simplification: Focus on concrete rather than abstract concepts
• Repetition: Key therapeutic concepts may need reinforcement
• Caregiver involvement: When appropriate, including a support person can enhance therapy effectiveness

Monitoring Cognitive Status During Treatment

• Regular reassessment with the MoCA is recommended every 6-12 months 1
• If cognitive status declines significantly, therapeutic approaches should be adjusted accordingly
• The 5-minute protocol version of the MoCA can be used for more frequent monitoring 1

Specific Psychotherapy Approaches

Different psychotherapeutic modalities may be more suitable depending on the specific cognitive profile:

• Cognitive Behavioral Therapy (CBT): Effective for patients with mild cognitive impairment, especially with adaptations for memory difficulties 1
• Problem-Solving Therapy: Focuses on concrete issues and solutions
• Supportive Psychotherapy: Less cognitively demanding
• Mindfulness-Based Interventions: Can be adapted for those with mild cognitive limitations

Conclusion

A MoCA score of 25 should not be a barrier to psychotherapy participation. With appropriate adaptations based on the individual's specific cognitive strengths and weaknesses, psychotherapy can be an effective intervention. The key is to match the therapeutic approach to the person's cognitive profile and to monitor cognitive status throughout treatment.