Chapter 4 102 identifying MCI, we favor a cutoff of <26, with a sensitivity of 94%, compared to a cutoff of <25 with a sensitivity of 88% despite the latter having a better Youden index by 2%. Our study showed that the MoCA was excellent at confirming normal cognition amongst patients suspected of CI and thereby very helpful in triaging, i.e. the decision if they indeed need to be referred to a memory clinic. Depending on the accessibility of further diagnostic workup, one can vary the cutoff score and thereby change the amount of FP and FN. Being aware of the patient’s high education level or FTD-symptoms would even lower the FN as shown in this study. A strength of our study was that the cohort consisted of patients where the clinician wanted further diagnostics. Not merely the patient’s (lack of) subjective complaints was decisive, nor psychiatric comorbidity for in- or exclusion. This cohort design comes with a limitation: all MoCA scores were included independent of the compliance during theMoCA assessment. Clinical judgment could also be used to lower the FP, especially those lacking motivation during the assessment. Again, one should be cautious of not missing MD with depressed or psychotic symptoms. Even if one could rule out all psychiatric causes of MCI before referral, our findings showed that 50% of the MCI-due to a neurodegenerative process (MCI-ND) scored below 21. Despite their low MoCA scores, these patients still clinically didn’t have dementia, as they were mostly IADL independent (GDS score of 3). Because by Dutch law only a psychiatrist can initiate compulsory referrals and our old age psychiatry led memory clinic offers also non-pharmacological home therapies this results in more advanced dementia referrals (severe dementia, BPSD and compulsory referrals), including from other memory clinics, to our clinic. Hence the fast numbers of excluded patients with a clear diagnosis of severe dementia. This could be an explanation why, after applying the exclusion criteria of this study, the prevalence of Alzheimer’s dropped from 61% at referral to old age psychiatry to 33% (23/83) in the study population. This could be a possible limitation of our study as we did not include all patients and that this (may have) influenced our findings, as we deliberately excluded all obvious and known causes and severe CI, e.g. BPSD and severe dementia (GDS ≥5). However, this may also be considered a strength of this validation of the MoCA where only patients suspected of CI – excluding the extremes of the spectrum as STARDdem dictates – were included. We believe that this is closer to the clinical reality as a triage tool has no added value for patients with obvious clinical symptoms of severe dementia. They don’t need triaging but need further work-up in case etiology has still to be identified. This also counts for the excluded patients with delirium, substance abuse or brain injury. Even though this comes with a risk of having omitted cases of vascular and/or mixed dementia.
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