The MoCA with a double threshold 5 127 Psychiatric comorbidities, such as depression or mania, only substantially influence the MoCA score in some individuals (Gierus andMosiolek, 2015; Blair et al., 2016; Dautzenberg et al., 2021; Korsnes, 2020), making beforehand stratification of these patients infeasible. This underscores that the MoCA should not be used as a stand-alone or overrule but should help clinical judgement as an add-on by knowing its strength (NVP, sensitivity) and weakness (PPV, specificity). A strength of our study is that possible psychiatric causes of CI were not excluded, as (cloaked) psychiatry is the clinical reality in most settings, especially in old-age psychiatry. Another strength is that we used a clinical cohort setup by avoiding the extremes of the spectrum, such as community-based healthy controls, and severely demented including those with BPSD, following the STARDdem recommendations. Therefore, the cohort consisted of patients a clinician would consider screening for CI. Including severe dementia would give better results due to a higher dementia prevalence and lower MoCA scores but this is not the clinical reality. Our setting on the other hand, is also a limitation, as referrals with BPSD and MCI caused by psychiatric aetiology will be higher than those in nonpsychiatric settings and will influence the prevalence of MD. However, our previous study showed that the mean MoCA score did not differ between neurodegenerative and psychiatric aetiologies of MCI (Dautzenberg et al., 2021). A limitation of our study is the uncertainty of the number of FNs after initial assessment. The consecutive cohort design resulted in ‘unsuspected patients after initial assessment’ (n= 403) not receiving an NPA due to practicality and resource constraints. We minimised this flaw by following these patients for at least 2 years. Three out of 403 unsuspected patients progressed to CI, most likely new cases. This corresponds with the incidence of 6.6 males or 7.4 females in the 74-79 age group (Volksgezondheidenzorg.info, 2019). Nonetheless we labelled them as if they were FN at the initial assessment. As stated before clinicians tend to refer when in doubt to minimise their FNs, which adds to their low FNs in this study. This favours the add-on strategy, but it also mimics the clinical reality. The acceptance of the amount of FN next to the availability of an NPA will influence where one puts the cut-off for referring to an NPA. Simply changing a single cut-off will not improve the number of classification errors (Landsheer, 2020). With a second cut-off for monitoring, one can consider the pros and cons of lowering sensitivity against the gain of specificity but avoid absolute or binary decision errors. We also considered the use of a third cut-off, meaning below a certain score no referral is necessary as dementia is surely
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