Validating the MoCA for triaging 4 103 If one considers only the SNoCI as the absolutely unwanted referrals to a memory clinic and the MCI not, as they have a higher risk of developing dementia, the specificity raises to 73% and the PPV to 90% (<21). However, the degree of being unwanted depends on the availability of resources, especially in mid and low income countries where most demented live and up to 90% are not diagnosed (Alzheimer’s Disease International, 2018). It is still being debated whether the benefits of screening (e.g. early detection allows the improvement of clinical care and management of dementia) (Baune & Renger, 2014; Pendlebury et al., 2015) outweigh potential harms (e.g. false positive referrals with emotional and financial burden) (Borson et al., 2013; Brunet et al., 2013; Burn et al., 2018; Le Couteur et al., 2013; Lin et al., 2013). The MoCA also comes with its cost: training and assessing-time. Still there are more and more advocacy groups or policy makers that recommend screening, especially for higher risk populations (Alzheimer’s Disease International, 2018; Borson et al., 2013; Cordell et al., 2013; Janssen et al., 2017; Pendlebury et al., 2015). As our patients were believed to be at high risk, and their quality of life seems not to be altered by the assessment(Janssen et al., 2019; McCarten et al., 2011), the use of a short triaging test prior to referral to ourmemory clinic seems beneficial and may add to a better use of limited resources (Janssen et al., 2019; McCarten et al., 2011). One might question if our setting is comparable to other (non-old age psychiatry) memory clinic settings, as our prevalence of MCI was high due to psychiatric diseases causing cognitive complaints. But we showed that by leaving out all psychiatric causes of MCI, the median stayed 21. A lower prevalence of MCI would result in better PPV, without changing the sensitivity. 4.5 Conclusions Given the above limitations, our overall conclusion is that the MoCA is not suitable for differentiating dementia, but that it is a good tool for screening for MD and MCI even in the old age psychiatry setting and has added value for triaging who is not in need of a specialized diagnostic route. This applies especially in settings where memory clinics are scarce and efforts have to be made to reduce the absolute number of referrals for full diagnostic work-up, without missing those patients in need of further assessment. 90% of those with a MoCA score of <21 will have CI (MD and MCI), while 94% of those with a MoCA of ≥21 will not have dementia.
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