Carolien Zeetsen

41 CHAPTER Psychometric properties of the MoCA in healthy participants 2 results are clearly also relevant for the use and interpretation of other–language versions of the MoCA. Limitations to the current study are, firstly, the non–orthogonal design, resulting in a relatively small group for comparing version 7.1 with version 7.3, and making it unable to compare version 7.2 with version 7.3, and secondly, that only self–reported exclusion criteria were used rather than an objective measure of cognitive impairment. With respect to the clinical implications of our results, it is clear that an adjustment for education (either for level or years) is essential, as originally proposed by Nasreddine et al. (2005), and recently fine–grained by Bruijnen, Jansen, et al. (2019). However, further research is needed in order to examine if a better adjustment method can be generated. For instance, more elaborate stratified or regression–based normative data could be constructed, like those of Borland et al. (2017) who proposed normative Swedish data that adjust the total score for age, education and sex. Furthermore, it should be noted that a ceiling performance was found for a substantial number of healthy participants for the MoCA–MIS, indicating that this index may be insensitive to small cognitive decrements in some clinical populations. Some of the shortcomings of MoCA version 7 might be overcome in the recently published version 8. When comparing the English–language versions 7 to versions 8, no changes were seen in version 1, while in versions 2 and 3 only about half of the items remained the same (i.e. the figures are all ‘cube’–like, using only straight lines, and the digits are randomised rather than changed). For the Dutch translation, only version 8.1 has been made available yet, for which one word of the memory subtest was replaced. As for the scoring and administration instructions, changes have been made by clarifying some of the ambiguities in instructions that lead to personal interpretation in the scoring of version 7 (i.e. the possibility to repeat instructions, clarifications for scoring the executive/ visuospatial items, simplified instructions for the verbal fluency, the adding of multiple– choice cues), but also the MoCA–MIS is included as a stand–alone score. If these changes/ additions are, in fact, overcoming the shortcomings should be examined in more detail in future research, when MoCA version 8 becomes more widely available. Based on both MoCA–TS and –MIS the Dutch translations of the MoCA are comparable to the English–language versions in their equivalence across versions and their test–retest reliability. Comparisons of the MoCA–DS should, however, be interpreted with caution. Although performance is affected by age, education and intelligence, adequate psychometric properties were found. The test–retest reliability can be used to determine change over time by calculating a reliable change index, adding to the clinical usability of the MoCA. After some training and following strict instructions the screener is easy to score, and was also reported as being acceptable in terms of clarity and difficulty for those undergoing it.