Carolien Zeetsen

134 Clinical consideration Now, at the end of this project availability of the MoCA has risen to over 100 languages in 60 countries. The test has been under constant development, as there are different forms available, for instance for telephone screening or blind subjects, but also an app version is now available. Research regarding the MoCA is rapidly expanding. Where only a few studies had investigated usability and feasibility of the MoCA in addiction care at the start of my PhD project, the amount of published papers on this subject has gradually grown, and is still growing since then. The MoCA does not conform to the criteria of an ideal cognitive screening instrument, as performance is not independent of age, educational level, premorbid intelligence and substance type. Therefore, more elaborate stratified or regression–based normative data should be constructed, adjusting for influences of age, education and intelligence. Nevertheless, the MoCA is a cognitive screening instrument and not a diagnostic measure. Thus, even if a screener has excellent sensitivity and specificity, an NPA remains the gold standard for diagnostic purposes, as well as for the specification of specific cognitive profiles. During the course of this project, we found that awareness of cognitive impairments (NCD) in addiction health care has grown, and is still growing. See, for instance, the recently published comprehensive textbook by Verdejo–García (Cognition and addiction: a researcher’s guide from mechanisms towards interventions; 2020). When using the MoCA to screen for cognitive impairments in addiction care, it is important to take age, educational level and substance type into account when interpreting results. The MoCA–TS and MoCA–MIS are the most reliable and valid scores, where the other MoCA–DS are not. If one does look at MoCA–DS, low scores on the memory domain seem to be predictive of alcohol–induced NCD, where no improvement over time further seems to indicate a major alcohol–induced NCD. The MoCA can also be used to monitor cognitive performance during the course of treatment, with an improvement in cognitive performance seen in the first six weeks of clinical admission, but also further during treatment. One should always be aware of the sensitivity and specificity at several cut–off scores. If you do not want to miss a patient with cognitive impairments, consider raising the cut– off score prior to assessment, while a lower predetermined cut–off lowers the chance of falsely indicating impairments when none exist. The confirmed lack of illness insight into cognitive functioning also states the importance of screening at an early stage of health care, so that results can help in appropriate decision making.