Chapter 5 112 ABSTRACT Objectives: Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of a neuropsychological assessment (NPA) is welcome. The Montreal cognitive assessment (MoCA) has high sensitivity at the original cut-off <26 for MD, but results in too many false positive referrals in clinical practice (low specificity). A cut-off that finds all patients at high risk of MD without referring too many patients not (yet) in need of an NPA is needed. A difficulty is who is to be considered at risk, as definitions for disease (e.g. MD) do not always define health at the same time and thereby create subthreshold disorders. Methods: In this study we compared different selection strategies to efficiently identify patients in need of an NPA. Using the MoCA with a double threshold tackles the dilemma of increasing the specificity without decreasing the sensitivity, and creates the opportunity to distinguish the clinical (MD) and subclinical (MCI) state and hence to get their appropriate policy. Setting/participants: patients referred to old age psychiatry suspected of cognitive impairment that could benefit from an NPA (n=693). Results: The optimal strategy was a two-stage selection process using the MoCA with a double threshold as an add-on after initial assessment. By selecting who is likely to have dementia and should be assessed further (MoCA<21), who should be discharged (≥26) and who’s course should be monitored actively as they are at increased risk (21<26). Conclusion: By using two cut-offs the clinical value of the MoCA improved for triaging. A doublethreshold MoCA not only gave the best results; accuracy, PPV, NPV and reducing false positives referrals by 65%, still correctly triaging most MD-patients. It also identified most MCIs whose intermediate state justifies active monitoring.
RkJQdWJsaXNoZXIy MTk4NDMw