10 min read – fact checked
Disclaimer: Anything discussed in this blog is not a medical diagnosis, prognosis, or a guarantee of future outcomes.
Brief presentation of the client
A 57 year old male client presented with declining memory concerns, suspected Mild Cognitive Impairment (MCI) and a history of a suspected traumatic brain injury (TBI) sustained during participation in contact sports during his early twenties. The client’s goal was to seek professional support to optimise his brain health and avoid further memory deterioration. The client underwent a thorough dietary analysis and health & symptoms questionnaire before being recommended a personalised dietary and lifestyle programme, and the client was not on any prescribed medications throughout the duration of the programme. He was also cognitively screened and tracked over three timepoints during a period of 14 months using a validated, peer-reviewed cognitive assessment tool known as the Montreal Cognitive Assessment (MoCA), validated to detect MCI for 55-85 year olds with a high degree of sensitivity and specificity (1). In the following blog post, I discuss in layman’s terms the client’s progress over the course of a year and two months with my professional support, which suggested remarkably improved brain function, read on.
A brief intro on the MoCA test
MoCA (Montreal Cognitive Assessment or The MoCA Test) is a short interactive test across various domains (figure 1), which has been validated as a highly sensitive tool for early detection of MCI in hundreds of peer-reviewed studies since 2000. MoCA has been widely adopted in clinical settings and used in academic and non-academic research around the world. The sensitivity of MoCA for detecting MCI is 90%, compared to 18% for the Mini-Mental State Examination (MMSE), a test often used to detect Alzheimer’s disease. Andrew Fortuna is certified to administer the test (figure 2).
CLICK to learn more about the MOCA test
The MoCA is highly sensitive to mild cognitive changes. Studies suggest that it can detect over 90% of MCI cases, outperforming older screening tools such as the MMSE. However, its specificity is more moderate, meaning some cognitively normal individuals may score below the cutoff, highlighting the importance of interpreting results in context of the individual’s health history.
Any clinician, health professional, researcher or worker who has successfully completed the official MoCA training and certification module can administer and score MoCA. Only health professionals with expertise in the cognitive field should interpret the results. To ensure consistency and accuracy, training and certification has been mandatory since September 1st 2019.
What exactly is MCI and TBI?
MCI is a noticeable decline in memory or thinking that is greater than normal aging but does not significantly interfere with daily life, and can occur from mid-life onward and suspected by a wide range of symptoms, particularly in individuals with risk factors such as TBI (3), vascular disease, or metabolic syndrome (2). Population studies indicate that approximately 10–20% of adults over 65 have MCI, and the prevalence increases with age (4). 10–15% of people with MCI convert to dementia each year (5), and around 50–60% MCI patients progress to dementia within 5 years (6). Detecting MCI early, represents a window of opportunity for intervention, the main aim of my preventative programme, which can help to:
– Act early before irreversible damage occurs.
– May help reduce dementia risk
– Detect subtle cognitive deficit early via MoCA & MIS
– Identify modifiable risk factors
– Monitor cognitive trajectories over time
TBI refers to current or past damage to the brain caused by a sudden blow or impact to the head, and a history of TBI can shift risk of MCI to an earlier age as suspected in this client, making monitoring from mid-50s or earlier prudent (7). Individuals with a history of moderate or severe TBI in early adulthood are at increased risk for MCI decades later, including MCI and early-onset dementia (8,9), with a wide variety of symptoms. Proposed mechanisms include:
– Chronic neuroinflammation
– Axonal injury and white matter changes
– Reduced cognitive reserve
In this client, the suspected TBI may have contributed to early memory and cognitive changes, which was detected and suspected by the MoCA and MIS at baseline (24/11/24).
MOCA and Memory Index Scores (MIS) over the 14 months
I will now briefly discuss the findings and the significance of the client’s three MoCA test scores that evaluated global cognitive scores and MIS scores throughout the 14 months (figure 3). The tests were carried out approximately 6-8 months between each other, utilising different versions of the test to reduce familiarity and potential learning effects.
MoCA global cognition & MIS at baseline 24th Nov 2024)
The first MoCA test results returned a global cognitive score of 22/30 (fig.6), highly suggestive of amnestic MCI (aMCI)I, four points below the normalcy threshold of 26/30. For context, 10–15% of people with MCI convert to dementia each year (5), and around 50–60% progress to dementia within 5 years (6). The client also had a particular difficulty in memory recall performance known as the MIS, with a MIS score of 6/15, which carries a higher risk of progression to dementia, particularly within the context of a suspected TBI.
CLICK to learn what MIS, MoCA global cognitive scores, and aMCI means
MIS is a score out of 15 that reflect how well a person learns and recalls information, providing a more detailed measure of memory performance than the total MoCA (global cognitive) score.The MoCA global cognitive scores are a simple measure of overall thinking and memory abilities. aMCI is a condition where a person has noticeable memory problems, especially with learning or recalling new information, that are greater than expected for their age, but not severe enough to interfere significantly with daily life or meet the criteria for dementia. aMCI carries a higher risk of progression to dementia.
MoCA global cognition & MIS scores 6 months later (13th May 2025)
The second MoCA test returned a score of 22/30 (fig.4), mirroring the score of the first test (24/11/24), while the MIS significantly improved from 6/15 to 11/15 in to normalcy. Evidence suggests that when MIS improves substantially while global scores remains stable, it suggests functional improvement in memory encoding and retrieval as a result of a 5–6 point increase in MIS (8-10), far exceeding what would be expected from MoCA test–retest variability alone – see below. Importantly, The overall results in May 2025 indicated no further deterioration in brain function, which was a significant positive finding and contrasts with progressive MCI, where memory typically declines steadily (10).
Click to learn what VARIABILITY means
Variability refers to the amount a test score can naturally go up, or down, even when a person’s true cognitive ability has not actually changed. In other words, If nothing meaningful changes in the brain, scores can still vary a bit. That small change is called the test–retest variability. Variability can happen as a result of day to day fluctuations, testing conditions, familiarity with the MoCA test, or measurement errors. A typical MoCA total score test–retest variability is about ±1 point, and that practice effects may add ~0.7–1.5 points, so a 1–2 MIS points of change may occur without true cognitive changes, which may have occurred by chance when the total MoCA score is viewed in isolation, ie without considering the MIS and the individual other risk factors. Practice effects refer to score improvements that occur simply because a person becomes familiar with the test format or questions through repeated testing, rather than due to real changes in cognitive ability.
MoCA global cognition & MIS scores 8 months later (8th Jan 2026)
Eight months on from his last MoCA test on May 2025 (fig.4), the client’s MoCA global score increased from 22/30 to 24/30. Although 24/30 is still below the threshold for normalcy (26/30), the observed change of +2 points, exceeds acknowledged variability thresholds (~±1 point), suggesting a reliable change threshold commonly used in clinical settings. The client’s MIS increased only slightly (11/15 → 12/15) and then appeared to plateau, which was not memory decline, but rather suggested that memory stabilisation occurred after recovery, with global cognition almost achieving normal brain function which is remarkable considering the client’s suspected TBI! The intervention was very safe and effective, and no adverse effects were observed (as expected).
Individual domain scores over the 14 months
I now discuss a brief interpretation of the scores across individual domains over the fourteen months, the observed changes, stability, trends and what they mean to the client’s brain function and dementia risks going forward. It is not meant as a diagnosis or prognosis.
1. VISUOSPATIAL AND EXECUTIVE FUNCTION
Planning, organisation, visual problem-solving, and mental flexibility.
Client scores over time:
Nov 2024: 3 / 5
May 2025: 3 / 5
Jan 2026: 4 / 5
What do these results mean?
The improvement seen by January 2026 suggests stronger executive control and visual reasoning. This is clinically meaningful because executive function is often vulnerable in Mild Cognitive Impairment. Gains in this area are unlikely to be due to chance alone and often reflect genuine functional improvement rather than test familiarity.
2. NAMING
The ability to correctly name objects, reflecting word retrieval and language access.
Client scores over time:
Nov 2024: 3 / 3
May 2025: 3 / 3
Jan 2026: 3 / 3
What do these results mean?
Naming remained stable and intact throughout. This is important because language decline can be an early marker of neurodegenerative disease. Stability here suggests preserved language networks.
3. ATTENTION
Sustained focus, mental tracking, and working memory. Examples include following
conversations, doing mental arithmetic, or staying focused without distraction.
Client scores over time:
Nov 2024: 2 / 6
May 2025: 3 / 6
Jan 2026: 3 / 6
What do these results mean?
The early improvement followed by stabilisation suggests partial recovery with a plateau. Attention is highly sensitive to stress, sleep, inflammation, metabolic health, and brain injury history, so even small improvements here are functionally meaningful.
4. LANGUAGE
Sentence repetition and verbal fluency
Scores over time:
Nov 2024: 2 / 3
May 2025: 2 / 3
Jan 2026: 3 / 3
What do these results mean?
Improvement by January 2026 reflects better verbal fluency and sentence processing, often linked to frontal-temporal brain networks. This change is unlikely to be explained by test-retest effects alone.
5. ABSTRACTION
The ability to identify similarities between concepts
Scores over time:
Nov 2024: 2 / 2
May 2025: 1 / 2
Jan 2026: 0 / 2
What do these results mean?
Abstraction is linked to executive and frontal-lobe–mediated reasoning, which can fluctuate more than memory or orientation domains, particularly in individuals with prior TBI. Nevertheless, the score changes represent a narrow, variable domain and do not invalidate evidence of overall cognitive stability or improvement when considered alongside the client’s total MoCA and MIS trajectory and longitudinal pattern.
6. DELAYED RECALL (MEMORY)
The ability to store and retrieve new information after a delay,
and the core component of the Memory Index Score (MIS).
Scores over time:
Nov 2024: 1 / 5
May 2025: 3 / 5
Jan 2026: 4 / 5
What do these results mean?
This is the most clinically significant improvement across all domains. A three-point increase in delayed recall exceeds expected test variability and strongly suggests real improvement in memory encoding and retrieval, rather than practice effects. In MCI, memory typically declines over time, so the improvement is a significant indicator of reduced risks of progression and conversion to dementia.
7. ORIENTATION
Awareness of the present
Scores over time:
Nov 2024: 6 / 6
May 2025: 6 / 6
Jan 2026: 6 / 6
What do these results mean?
Orientation remained intact throughout, indicating preserved basic cognitive awareness and supporting the absence of more advanced cognitive decline.
Summary of the individual domains
Why these changes matter clinically
Across the three time points, the pattern showed:
– Stability where decline would normally be expected
– Meaningful improvement in memory and executive domains
– No evidence of global deterioration
In clinical research, people with untreated MCI typically show gradual decline over 12–24 months. Seeing improvements, particularly in delayed recall, strongly suggests that underlying mechanisms affecting cognition may have shifted in a favourable direction, reducing the risks of conversion to dementia.
Key domain findings
Looking beyond the MoCA global cognitive score reveals a powerful story for this client. Memory, executive function, and language showed clear improvements, while other domains predominantly remained stable. For a person with suspected aMCI, this pattern is clinically meaningful, encouraging, and consistent with a positive cognitive trajectory.
Balanced discussion of the findings
Does ‘chance’ explain these findings?
So let’s suppose for a second that the 2 point increase in MoCA total (global cognitive) scores (22/30 – 24/30) eight months on from his previous MoCA test in May ’25, had occurred without true cognitive changes. Can this increase in MoCA total score be explained by variability, and could they have occurred by chance?
Extremely unlikely. The reason being that when a 2 point increase in MoCA global scores occurs in conjunction with a 5–6 point MIS increase, the combined increase falls far beyond what would ordinarily be expected by global score variability, suggesting that the MIS increase was highly unlikely to have occurred by chance, and very likely evidence of real memory improvement. In science, small changes are often referred to as as ‘noise’, but when large magnitude changes (+5-6 MIS pts) occur it points towards a very strong ‘signal’. The outcomes therefore are not merely a marginal change, but rather a categorical shift, which is why the improvements observed in this client are considered scientifically robust and clinically meaningful.
Additionally, my MoCA tests were conducted 6-8 months apart from each, as well as using different validated versions of the MoCA which further reduces the risk of familiarity and a ‘learning effect’, making the findings even more robust and reliable.
What else supports these findings?
The temporal sequence is also crucial. Temporality refers to the order in which events occur over time, helping determine whether one event precedes and may contribute to another. The memory improvement which occurred before the global improvement suggested improved encoding/retrieval, a pattern often seen cognitive improvement, and not masking of deficits, whilst the subsequent global improvement in the client’s third MoCA test (Jan 2026) suggests downstream benefits across a number of domains. The temporal pattern in this case is inconsistent with progressive neurodegeneration, and consistent with reduced cognitive load and functional recovery, which all things considered, may potentially only be explained by the client’s personalised dietary and lifestyle recommendations from my brain optimisation programme.
Is brain imaging required to confirm these findings?
Critics may argue that brain imaging is required to confirm these findings. However, the published literature does not support this view. Brain imaging is not necessary to establish clinical significance because it primarily detects structural changes or gross pathology, and does not directly measure cognitive function, as evidenced by a Cochrane review (13). Furthermore, brain structure may remain normal in early MCI, post-traumatic brain injury (TBI) syndromes, and functional cognitive disorders (12), whilst imaging is not recommended for aMCI (11). Cognition is fundamentally a functional outcome best assessed through validated cognitive testing, such as the MoCA, and longitudinal changes in cognitive performance over time are often more predictive of prognosis than a single magnetic resonance imaging (MRI) snapshot (12). Indeed, routine clinical practice and many dementia prevention trials often use changes in MoCA scores over time as primary or secondary endpoints without requiring imaging, thereby establishing clear precedent.
Considering the client’s history of TBI
The client’s suspected history of TBI makes the findings even more impressive, strengthening the significance of the cognitive and memory improvement. This is because sustained improvement is less common in TBI without an intervention (14), whilst the client’s baseline cognitive reserve may have been reduced as a result of the brain injury causing brain decline to emerge earlier and progress faster (15). Therefore, the evidence presented, strongly suggests that the personalised dietary and lifestyle recommendations may have led to the positive outcomes, which may have been as a result of increased neuroplasticity, compensatory mechanisms, and/or risk factor modifications, particularly noteworthy given the client’s decades-long interval between his intervention and his suspected brain injury.
Are findings irrefutable?
There are some limitations and uncertainties. Despite being certified to administer the MoCA, I cannot independently confirm the results, make a diagnosis, or provide a prognosis. The results do not guarantee that the client will not progress to dementia, and the MoCA results would need to be confirmed by a neuropsychiatrist, so nuance and caution is warranted. However, although the MoCA results have not been formally validated by a suitably qualified mental health professional, the rigour of the methodology used to reach these conclusions cannot be disregarded, therefore, the evidence remains robust, highly reliable, and clinically meaningful.
Overall summary and conclusions
The magnitude and trajectory of change significantly exceeded what would ordinarily be expected from test–retest variability and are consistent with a progressive neuro-regenerative trajectory and functional recovery, and inconsistent with with an active dementia disease process. Even in the absence of brain imaging, these longitudinal cognitive improvements are robust and clinically significant, suggesting preserved brain function and reduced short-term risk of progression to dementia at present. Going forwards, work will continue to ensure gains are stabilised and maintained, and (hopefully) continue making smaller improvements.
BRAINCOG: My brain optimisation programme
Click to learn about ANDREW FORTUNA NT
Andrew Fortuna studied Nutrition Science (BSc) Hons and Personalised Nutrition (MSc) based on a systems biology approach, a holistic and integrative method used to understand complex biological systems by analysing their interconnected components, rather than studying individual parts in isolation. It involved a deep emphasis on nutritional biochemistry, and the influence of nutrients and food components on cellular and molecular pathways involved in the pathophysiology of a wide range of chronic diseases using evidence-based pathophysiological reasoning. Clinical training, required to meet UK National Occupational Standards, involved being able to apply all this knowledge to four supervised clients experiencing a wide range of chronic health conditions to help ameliorate or prevent disease based on the Functional Medicine Model.
For his undergraduate BSc (Hons) research project and postgraduate Masters dissertation, he specialised his studies on brain energy metabolism in Mild Cognitive Impairment (MCI) and Alzheimer’s disease, as well as dietary interventions for the prevention of MCI and Alzheimer’s disease, especially for carriers of the Apolipoprotein E4 (aka ‘the Alzheimer’s gene’).
– MSc PERSONALISED NUTRITION (Middlesex University)
– BSc (Hons) NUTRITIONAL SCIENCE (Middlesex University)
– PERSONALISED NUTRITION PRACTICE DIPLOMA
– REGISTERED NUTRITIONIST (mBANT)
– REGISTERED NUTRITIONAL THERAPY PRACTITIONER (CNHC)
– ANATOMY & PHYSIOLOGY DIPLOMA
– BLOOD CHEMISTRY ANALYST
– MONTREAL COGNITIVE ASSESSMENT (MoCA) rater
– NEURO-LINGUISTIC PROGRAMMING (NLP) PRACTITIONER
– LABORATORY TESTING & ANALYSIS
Why sign up to my brain optimisation programme?
This case study highlights why early monitoring and early action matters because cognitive decline is not always a one-way path, especially when changes are identified and addressed early, and MCI is a strong risk factor for Alzheimer’ disease, Neuropathological changes associated with Alzheimer’s disease begins years or even decades before a diagnosis, often during midlife. By the time dementia is clinically apparent, neuronal loss is extensive and treatment options are limited. Acting earlier in mid-life, as this client did with the help of my programme, allows for early risk identification, monitoring of changes, and targeted diet and lifestyle interventions that may slow, stabilise the decline, or like in this case, even improve brain function compared to baseline. My programme would also be suitable for persons at risk of or with a family history of dementia, and even recreational or professional athletes involved in contact sports at risk of a head injury.
This prevention-oriented approach aligns with modern dementia research, which increasingly emphasises risk reduction rather than late-stage treatment, and an example of how modern brain health and dementia risk reduction works, not by waiting or doing nothing, but by measuring, tracking, and acting early. So if you’re interested in a personalised, evidence-informed programme that monitors cognitive function over time and supports brain health proactively, my programme is designed for exactly that purpose. SIGN UP NOW and learn more about my brain and memory optimisation programme by clicking HERE, or fill out the form below to get in touch with me for a no obligation 15 min free consultation to ask any questioning before committing.
- Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment. J Am Geriatr Soc. 2005;53(4):695–9.
- Davis DHJ, Creavin ST, Yip JLY, et al. Montreal Cognitive Assessment for the diagnosis of Alzheimer’s disease and other dementias. Cochrane Database Syst Rev. 2021;7:CD010775.
- Johnson VE, Stewart W, Smith DH. Traumatic brain injury and risk of dementia. Lancet Neurol. 2017;16(12):1122-1132.
- Ward A, Arrighi HM, Michels S, Cedarbaum JM. Mild cognitive impairment: prevalence and incidence. Alzheimers Dement. 2012;8(4):279-287.
- Mitchell AJ, Shiri-Feshki M. Rate of progression of MCI to dementia. Acta Psychiatr Scand. 2009;119(4):252-265.
- Krishnan K, Rossetti H, Hynan LS, et al. Changes in Montreal Cognitive Assessment scores over time. J Aging Health. 2017;29(5):772-788
- Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care. Lancet. 2020;396(10248):413-446.
- Julayanont P, Brousseau M, Chertkow H, et al. MoCA Memory Index Score as a predictor of conversion from MCI to Alzheimer’s disease. Alzheimer Dis Assoc Disord. 2014;28(4):1-6.
- Fleminger S, Oliver DL, Lovestone S, Rabe-Hesketh S, Giora A. Head injury as a risk factor for Alzheimer’s disease: the evidence 10 years on; a partial replication. J Neurol Neurosurg Psychiatry. 2003;74(7):857-862.
- Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med.2004;256(3):183-194.
- Paul R, Lane EM, Tate DF, Heaps J, Romo DM, Akbudak E, et al. Neuroimaging Signatures and Cognitive Correlates of the Montreal Cognitive Assessment Screen in a Nonclinical Elderly Sample. Arch Clin Neuropsychol. 2011 Aug;26(5):454–60.
- Petersen RC et al., Mild cognitive impairment: imaging data — diagnostic criteria for MCI are based on clinical observation, not solely imaging findings.
- Lombardi G, Crescioli G, Cavedo E, et al. Structural magnetic resonance imaging for the early diagnosis of dementia due to Alzheimer’s disease in people with mild cognitive impairment. Cochrane Database Syst Rev. 2020;3(3):CD009628. Published 2020 Mar 2. doi:10.1002/14651858.CD009628.pub2
- Sander D, Bartsch T, Connolly F, Enzinger C, Fischer U, Nellessen N, et al. Guideline “Transient Global Amnesia (TGA)” of the German Society of Neurology (Deutsche Gesellschaft für Neurologie): S1-guideline. Neurol Res Pract. 2023 Apr 20;5:15.
- Donders J, Stout J. The Influence of Cognitive Reserve on Recovery from Traumatic Brain Injury. Arch Clin Neuropsychol. 2019 Mar 1;34(2):206–13.
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