Validating the MoCA for triaging 4 87 4.1 Introduction Diagnosing, as well as the guidance and treatment of dementia, including Behavioral and Psychological Symptoms of Dementia (BPSD), is often done in old age psychiatry which, at least in the Netherlands, make up to 25% of all memory clinics (Verhey, et.al 2010). Here, patients with a wide variety of etiologies of possible cognitive impairment (CI) are presented- including major depressive- , schizophrenic- and bipolar- disorders. More referrals to memory clinics and old age psychiatry should be expected due to demographic reasons and more awareness of CI (Alzheimer’s disease International, 2016) alongside the trend of earlier assessment with less pronounced symptoms (Grimmer et al., 2015). A validated short tool to assess patients that are suspected of CI to objectify the complaints, before further referral, is necessary to triage who is indeed in need of an elaborate diagnostic investigation for dementia. This could help to relieve the pressure on diagnostic pathways (Alzheimer’s disease International, 2016; Davis et al., 2015), which are costly and scarce in most countries (Alzheimer’s Disease International, 2018). Especially as doctors without an objective test rather refer too early than too late to avoid a missed diagnose and this raises the false positive referrals. According to the Cochrane review, ‘the MoCA may help identify people requiring specialist assessment and treatment for dementia’ (Davis et al., 2015, p.5). General practitioners in the Netherlands are advised to use the Montreal Cognitive Assessment (MoCA) especially for patients with ‘possible CI’ but less so for ‘not likely’ or ‘likely’ CI patients (Janssen et al., 2017). Screening older patients with the MoCA is often recommended as subjective cognitive complaints agree poorly with objective cognitive deficit (Pendlebury et al., 2015) but results in toomany false positives in old age psychiatry (Dautzenberg et al., 2020). Using an objective test (the MoCA) only for suspected patients concurs with the above need for triaging possible impaired patients and is especially welcome in old age psychiatry, as the (subjective) cognitive complaints are numerous due to age (60+), psychiatric comorbidity (including psychotropic medication) causing CI next to CI as a primary reason for referral. The MoCA is a widely used short screening tool for mild cognitive impairment (MCI) and mild dementia (MD) (Alzheimer’s disease International, 2016; Davis et al., 2013; Nasreddine et al., 2005), validated in multiple settings and languages (Mocatest.Org). However, many of these studies were designed with a case-control set-up using healthy, community-based individuals as controls (Davis et al., 2015), which can result in spectrumbias (Dautzenberg et al., 2020; Davis et al., 2015; Noel-Storr et al., 2014), overestimating specificity. In literature, lower cutoff scores are repeatedly suggested for clinical use,
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